Provider Demographics
NPI:1699715979
Name:WICKRAMASINGHE, MOHANLAL (MD)
Entity type:Individual
Prefix:
First Name:MOHANLAL
Middle Name:
Last Name:WICKRAMASINGHE
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 1:3450 S ARCHER AVE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60608-6837
Mailing Address - Country:US
Mailing Address - Phone:773-523-1000
Mailing Address - Fax:773-843-1553
Practice Address - Street 1:3450 S ARCHER AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60608-6837
Practice Address - Country:US
Practice Address - Phone:773-523-1000
Practice Address - Fax:773-843-1553
Is Sole Proprietor?:No
Enumeration Date:2006-06-07
Last Update Date:2012-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036-047140208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036047140Medicaid
IL036047140Medicaid