1942215330 NPI number — ROHINI WIJETILLEKE MD PC

Table of content: (NPI 1942215330)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1942215330 NPI number — ROHINI WIJETILLEKE MD PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
ROHINI WIJETILLEKE MD PC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
FAMILY PRACTICE AND PEDIATRICS
Provider Other Organization Name Type Code:
3
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1942215330
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
11/29/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
100 ELDEN STREET
Provider Second Line Business Mailing Address:
SUITE 14
Provider Business Mailing Address City Name:
HERNDON
Provider Business Mailing Address State Name:
VA
Provider Business Mailing Address Postal Code:
20170
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
703-471-7733
Provider Business Mailing Address Fax Number:
703-471-7733

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
100 ELDEN STREET
Provider Second Line Business Practice Location Address:
SUITE 14
Provider Business Practice Location Address City Name:
HERNDON
Provider Business Practice Location Address State Name:
VA
Provider Business Practice Location Address Postal Code:
20170
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
703-471-7733
Provider Business Practice Location Address Fax Number:
703-471-7733
Provider Enumeration Date:
07/31/2006

Additional Information

Authorized Official

Authorized Official Last Name:
WIJETILLEKE
Authorized Official First Name:
ROHINI
Authorized Official Middle Name:
Authorized Official Title or Position:
MD PC
Authorized Official Telephone Number:
703-471-7733

Provider Taxonomy Codes

  • Taxonomy code: 207Q00000X , with the licence number:  35528 , registered in the state of VA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 208000000X , with the licence number: 35528 , registered in the state of VA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 210923 . This is a "BLUE CROSS BS" identifier . This identifiers is of the category "OTHER".
  • Identifier: 5618410 , issued by the state of ( VA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 281178 . This is a "AMERIGROUP" identifier . This identifiers is of the category "OTHER".
  • Identifier: 6711324 , issued by the state of ( VA ) . This identifiers is of the category "MEDICAID".




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