Provider Demographics
NPI:1396798120
Name:DEALWIS, WATUTANTRIGE TAKSHAN (MD)
Entity type:Individual
Prefix:DR
First Name:WATUTANTRIGE
Middle Name:TAKSHAN
Last Name:DEALWIS
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 1:71 BERKELY PLACE
Mailing Address - Street 2:
Mailing Address - City:ALPINE
Mailing Address - State:NJ
Mailing Address - Zip Code:07620
Mailing Address - Country:US
Mailing Address - Phone:201-750-1907
Mailing Address - Fax:
Practice Address - Street 1:223 N VAN DIEN AVE
Practice Address - Street 2:
Practice Address - City:RIDGEWOOD
Practice Address - State:NJ
Practice Address - Zip Code:07450-2726
Practice Address - Country:US
Practice Address - Phone:201-447-8586
Practice Address - Fax:201-447-8491
Is Sole Proprietor?:No
Enumeration Date:2006-05-19
Last Update Date:2011-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA042869002084P0804X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0804XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyChild & Adolescent Psychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ6358900Medicaid
F19838Medicare UPIN
NJ6358900Medicaid