Provider Demographics
NPI:1124306006
Name:WYNN, AVANTHIKA THANUSHI (MD)
Entity type:Individual
Prefix:DR
First Name:AVANTHIKA
Middle Name:THANUSHI
Last Name:WYNN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:DR
Other - First Name:AVANTHIKA
Other - Middle Name:THANUSHI
Other - Last Name:WEERASINGHE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:5665 PEACHTREE DUNWOODY RD
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30342-1764
Mailing Address - Country:US
Mailing Address - Phone:678-843-6497
Mailing Address - Fax:
Practice Address - Street 1:5665 PEACHTREE DUNWOODY RD
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30342-1764
Practice Address - Country:US
Practice Address - Phone:678-843-6497
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-07-27
Last Update Date:2019-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY275177208M00000X, 207R00000X
GA79142207RP1001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary Disease
No208M00000XAllopathic & Osteopathic PhysiciansHospitalist
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY03007063/NWKMedicaid
NY03007072/OPDMedicaid
NY01131126/RGHMedicaid
NY01131126/RGHMedicaid
NY70005A/RGHMedicare PIN
NYJ400148478Medicare PIN
NY10712A/NWKMedicare PIN