NPIMap

Individual provider Active NPI

Kumudinie C Fonseka, MD

  • Internal Medicine Physician
  • St Clair Shores, MI
National Provider Identifier
1376653089
Registry record updated Oct 22, 2012
On this page

Key facts

NPPES NPI Registry
Primary specialty
Internal Medicine PhysicianTaxonomy code 207R00000X
License
4301049484 Issued in MI
Practice address
21327 Harper Avenue
Suite D
St Clair Shores, MI 48080
Phone
(586) 772-2300
Fax
(586) 772-7111
NPI assigned
Aug 30, 2006
Sex
Female
Sole proprietor
No

NPPES NPI Registry

Updated by the provider on Oct 22, 2012

Registry information is reported by the provider to CMS and is not verified. About this source

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Internal Medicine Physician 207R00000X 4301049484 MI Primary

Addresses

Primary practice location

21327 Harper Avenue
Suite D
St Clair Shores, MI 48080

Mailing address

21327 Harper Avenue
Suite D
St Clair Shores, MI 48080
Phone (586) 772-2300

Other identifiers 1

IdentifierTypeStateIssuer
1943271MedicaidMI

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Not listed in the public Medicare enrollment file

National Provider Directory

National Provider Directory
Medicare enrollment (NPD)
Enrolled
Credentials
Doctor of Medicine

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1156896000000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1350864000000",
    "number": "1376653089",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "21327 HARPER AVENUE",
            "address_2": "SUITE D",
            "city": "ST CLAIR SHORES",
            "state": "MI",
            "postal_code": "48080",
            "telephone_number": "586-772-2300",
            "fax_number": "586-772-7111"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "21327 HARPER AVENUE",
            "address_2": "SUITE D",
            "city": "ST CLAIR SHORES",
            "state": "MI",
            "postal_code": "48080",
            "telephone_number": "586-772-2300",
            "fax_number": "586-772-7111"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "last_name": "FONSEKA",
        "first_name": "KUMUDINIE",
        "middle_name": "C",
        "credential": "MD",
        "sole_proprietor": "NO",
        "sex": "F",
        "enumeration_date": "2006-08-30",
        "last_updated": "2012-10-22",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "207R00000X",
            "taxonomy_group": "",
            "desc": "Internal Medicine",
            "state": "MI",
            "license": "4301049484",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "1943271",
            "state": "MI"
        }
    ],
    "endpoints": [],
    "other_names": []
}

Other providers in St Clair Shores, MI

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Oct 22, 2012; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
  • National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.