Provider Demographics
NPI:1790095040
Name:JAYASEKERA, CHANNA R (MD, MS, MSC)
Entity type:Individual
Prefix:DR
First Name:CHANNA
Middle Name:R
Last Name:JAYASEKERA
Suffix:
Gender:M
Credentials:MD, MS, MSC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13400 E SHEA BLVD
Mailing Address - Street 2:
Mailing Address - City:SCOTTSDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85259-5499
Mailing Address - Country:US
Mailing Address - Phone:408-301-8000
Mailing Address - Fax:904-953-0115
Practice Address - Street 1:13400 E SHEA BLVD
Practice Address - Street 2:
Practice Address - City:SCOTTSDALE
Practice Address - State:AZ
Practice Address - Zip Code:85259-5499
Practice Address - Country:US
Practice Address - Phone:408-301-8000
Practice Address - Fax:904-953-0115
Is Sole Proprietor?:No
Enumeration Date:2010-10-19
Last Update Date:2021-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA113689207R00000X, 207RG0100X
AZ63158207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAA113689OtherMEDICAL BOARD OF CALIFORNIA