Provider Demographics
NPI:1427450279
Name:WIJE KOTTAHACHCHI, MD FAAP
Entity type:Organization
Organization Name:WIJE KOTTAHACHCHI, MD FAAP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:WIJE
Authorized Official - Middle Name:
Authorized Official - Last Name:KOTTAHACHCHI
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:732-442-1820
Mailing Address - Street 1:468 AMBOY AVE
Mailing Address - Street 2:
Mailing Address - City:PERTH AMBOY
Mailing Address - State:NJ
Mailing Address - Zip Code:08861-3143
Mailing Address - Country:US
Mailing Address - Phone:732-442-1820
Mailing Address - Fax:732-442-2918
Practice Address - Street 1:468 AMBOY AVE
Practice Address - Street 2:
Practice Address - City:PERTH AMBOY
Practice Address - State:NJ
Practice Address - Zip Code:08861-3143
Practice Address - Country:US
Practice Address - Phone:732-442-1820
Practice Address - Fax:732-442-2918
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-09-24
Last Update Date:2014-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ2442809Medicaid