Provider Demographics
NPI:1316146632
Name:FERNANDO, THILAN PJ (MD)
Entity type:Individual
Prefix:DR
First Name:THILAN
Middle Name:PJ
Last Name:FERNANDO
Suffix:
Gender:M
Credentials:MD
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Mailing Address - Street 1:75 REMITTANCE DRIVE DEPT 6008
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60675-6008
Mailing Address - Country:US
Mailing Address - Phone:562-282-1419
Mailing Address - Fax:562-920-1446
Practice Address - Street 1:11480 BROOKSHIRE AVE
Practice Address - Street 2:SUITE #204
Practice Address - City:DOWNEY
Practice Address - State:CA
Practice Address - Zip Code:90241-5018
Practice Address - Country:US
Practice Address - Phone:562-282-2775
Practice Address - Fax:562-904-8095
Is Sole Proprietor?:Yes
Enumeration Date:2007-07-16
Last Update Date:2016-06-02
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Provider Licenses
StateLicense IDTaxonomies
CAA97365207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A973650Medicaid
CA00A973650Medicaid