1992327969 NPI number — MRS. CHANDIMA JINANI HERATH MUDIYANSELAGE M.D.

Table of content: MRS. CHANDIMA JINANI HERATH MUDIYANSELAGE M.D. (NPI 1992327969)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1992327969 NPI number — MRS. CHANDIMA JINANI HERATH MUDIYANSELAGE M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
HERATH MUDIYANSELAGE
Provider First Name:
CHANDIMA
Provider Middle Name:
JINANI
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
M.D.
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
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:
1992327969
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
11/19/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4201 ST. ANTOINE
Provider Second Line Business Mailing Address:
UHC 9C
Provider Business Mailing Address City Name:
DETROIT
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
48201
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
313-745-5147
Provider Business Mailing Address Fax Number:
313-993-8501

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
7565 DANNAHER DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
POWELL
Provider Business Practice Location Address State Name:
TN
Provider Business Practice Location Address Postal Code:
37849-4029
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
865-859-8000
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
05/13/2020

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207R00000X , with the licence number:  70459 , registered in the state of TN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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