Provider Demographics
NPI:1043236284
Name:KOTTAGE, JAYARATHNE (MD)
Entity Type:Individual
Prefix:DR
First Name:JAYARATHNE
Middle Name:
Last Name:KOTTAGE
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 1:1515 IDLEWILD BLVD
Mailing Address - Street 2:
Mailing Address - City:FREDERICKSBRG
Mailing Address - State:VA
Mailing Address - Zip Code:22401-6623
Mailing Address - Country:US
Mailing Address - Phone:240-778-3761
Mailing Address - Fax:540-368-7599
Practice Address - Street 1:300 PARK HILL DR
Practice Address - Street 2:
Practice Address - City:FREDERICKSBURG
Practice Address - State:VA
Practice Address - Zip Code:22401-3387
Practice Address - Country:US
Practice Address - Phone:540-368-7405
Practice Address - Fax:540-368-7599
Is Sole Proprietor?:No
Enumeration Date:2006-07-14
Last Update Date:2024-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2004021469208100000X
VA0101254569174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
No208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO209339001Medicaid
IL$$$$$$$$$Medicaid
924820101Medicare PIN
H92785Medicare UPIN
IL$$$$$$$$$Medicaid