Provider Demographics
NPI:1104811108
Name:WIJEWARDANE, PRIYANTHA NALINDA (MD)
Entity type:Individual
Prefix:DR
First Name:PRIYANTHA
Middle Name:NALINDA
Last Name:WIJEWARDANE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1505 W 11TH ST
Mailing Address - Street 2:
Mailing Address - City:LITTLE ROCK
Mailing Address - State:AR
Mailing Address - Zip Code:72202-4619
Mailing Address - Country:US
Mailing Address - Phone:501-376-1160
Mailing Address - Fax:501-376-3977
Practice Address - Street 1:1505 W 11TH ST
Practice Address - Street 2:
Practice Address - City:LITTLE ROCK
Practice Address - State:AR
Practice Address - Zip Code:72202-4619
Practice Address - Country:US
Practice Address - Phone:501-376-1160
Practice Address - Fax:501-376-3977
Is Sole Proprietor?:No
Enumeration Date:2005-09-15
Last Update Date:2009-12-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARE-1124207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR130532001Medicaid
5K306Medicare ID - Type Unspecified
G45289Medicare UPIN