Provider Demographics
NPI:1992327969
Name:HERATH MUDIYANSELAGE, CHANDIMA JINANI (MD)
Entity type:Individual
Prefix:MRS
First Name:CHANDIMA
Middle Name:JINANI
Last Name:HERATH MUDIYANSELAGE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:4201 ST. ANTOINE
Mailing Address - Street 2:UHC 9C
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48201
Mailing Address - Country:US
Mailing Address - Phone:313-745-5147
Mailing Address - Fax:313-993-8501
Practice Address - Street 1:7565 DANNAHER DR
Practice Address - Street 2:
Practice Address - City:POWELL
Practice Address - State:TN
Practice Address - Zip Code:37849-4029
Practice Address - Country:US
Practice Address - Phone:865-859-8000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-05-13
Last Update Date:2024-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN70459207R00000X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine