Provider Demographics
NPI:1154555811
Name:KAVIRATNE, SUMMANTHER T ANTHONY (MD)
Entity type:Individual
Prefix:
First Name:SUMMANTHER
Middle Name:T ANTHONY
Last Name:KAVIRATNE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:ANTHONY
Other - Middle Name:
Other - Last Name:KAVIRATNE
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:1802 YAKIMA AVE STE 307
Mailing Address - Street 2:
Mailing Address - City:TACOMA
Mailing Address - State:WA
Mailing Address - Zip Code:98405-5305
Mailing Address - Country:US
Mailing Address - Phone:253-627-1244
Mailing Address - Fax:253-627-6576
Practice Address - Street 1:1802 YAKIMA AVE STE 307
Practice Address - Street 2:
Practice Address - City:TACOMA
Practice Address - State:WA
Practice Address - Zip Code:98405-5305
Practice Address - Country:US
Practice Address - Phone:253-627-1244
Practice Address - Fax:253-627-6576
Is Sole Proprietor?:No
Enumeration Date:2009-05-11
Last Update Date:2023-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD61188393207RI0011X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Yes207RI0011XAllopathic & Osteopathic PhysiciansInternal MedicineInterventional Cardiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA2251622Medicaid