Basic Information
Provider Information | |||||||||
NPI: | 1235325507 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | GOMES CUMARANATUNGE | ||||||||
FirstName: | G. RESHMAAL | ||||||||
MiddleName: | DEEPTHI | ||||||||
NamePrefix: | DR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | MD | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | GOMES | ||||||||
OtherFirstName: | RESHY | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: | DR. | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: | MD | ||||||||
OtherLastNameType: | 2 | ||||||||
Mailing Information | |||||||||
Address1: | 5859 W TALAVI BLVD | ||||||||
Address2: | SUITE 100 | ||||||||
City: | GLENDALE | ||||||||
State: | AZ | ||||||||
PostalCode: | 853061869 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6022987777 | ||||||||
FaxNumber: | 6239306060 | ||||||||
Practice Location | |||||||||
Address1: | 5859 W TALAVI BLVD | ||||||||
Address2: | SUITE 100 | ||||||||
City: | GLENDALE | ||||||||
State: | AZ | ||||||||
PostalCode: | 853061869 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6022987777 | ||||||||
FaxNumber: | 6239306060 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 09/20/2007 | ||||||||
LastUpdateDate: | 08/26/2011 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RC0000X | 38019 | AZ | Y |   | Allopathic & Osteopathic Physicians | Internal Medicine | Cardiovascular Disease | 207UN0901X | 38019 | AZ | N |   | Allopathic & Osteopathic Physicians | Nuclear Medicine | Nuclear Cardiology |
ID Information
ID | Type | State | Issuer | Description | 318603 | 05 | AZ |   | MEDICAID |