Provider Demographics
NPI:1326624313
Name:SENEVIRATNE, ANGELO NISHAN (DO)
Entity type:Individual
Prefix:
First Name:ANGELO
Middle Name:NISHAN
Last Name:SENEVIRATNE
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2500 GASKINS RD STE A
Mailing Address - Street 2:
Mailing Address - City:RICHMOND
Mailing Address - State:VA
Mailing Address - Zip Code:23238-1480
Mailing Address - Country:US
Mailing Address - Phone:804-774-7099
Mailing Address - Fax:804-528-5864
Practice Address - Street 1:2500 GASKINS RD STE A
Practice Address - Street 2:
Practice Address - City:RICHMOND
Practice Address - State:VA
Practice Address - Zip Code:23238-1480
Practice Address - Country:US
Practice Address - Phone:804-774-7099
Practice Address - Fax:804-528-5864
Is Sole Proprietor?:No
Enumeration Date:2021-03-22
Last Update Date:2024-12-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
VA0102208638207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program