Provider Demographics
NPI:1104881523
Name:KUMARATNE, MOHAN PRIYAKANTHA (MD)
Entity type:Individual
Prefix:DR
First Name:MOHAN
Middle Name:PRIYAKANTHA
Last Name:KUMARATNE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:DR
Other - First Name:MOHAN
Other - Middle Name:PRIYAKANTHA
Other - Last Name:KUMARARATNE
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:17692 BEACH BLVD
Mailing Address - Street 2:STE. 200
Mailing Address - City:HUNTINGTON BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:92647-6837
Mailing Address - Country:US
Mailing Address - Phone:714-847-6975
Mailing Address - Fax:714-847-9727
Practice Address - Street 1:17692 BEACH BLVD
Practice Address - Street 2:STE. 200
Practice Address - City:HUNTINGTON BEACH
Practice Address - State:CA
Practice Address - Zip Code:92647-6837
Practice Address - Country:US
Practice Address - Phone:714-847-6975
Practice Address - Fax:714-847-9727
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-04-19
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA353272080A0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080A0000XAllopathic & Osteopathic PhysiciansPediatricsAdolescent Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A353270Medicaid