Provider Demographics
NPI:1013185115
Name:HERATH, PRIYANTHA (MD PHD)
Entity type:Individual
Prefix:DR
First Name:PRIYANTHA
Middle Name:
Last Name:HERATH
Suffix:
Gender:M
Credentials:MD PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:675 W KENDALL ST
Mailing Address - Street 2:
Mailing Address - City:CAMBRIDGE
Mailing Address - State:MA
Mailing Address - Zip Code:02142-1168
Mailing Address - Country:US
Mailing Address - Phone:202-997-0390
Mailing Address - Fax:
Practice Address - Street 1:675 W KENDALL ST
Practice Address - Street 2:
Practice Address - City:CAMBRIDGE
Practice Address - State:MA
Practice Address - Zip Code:02142-1168
Practice Address - Country:US
Practice Address - Phone:202-997-0390
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-02-12
Last Update Date:2024-11-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA2928502084N0400X
TXP06022084N0400X
VA01012542232084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC367007Medicaid
TXTXB137418Medicare PIN
SC367007Medicaid