Provider Demographics
NPI:1295003564
Name:HETTIARACHCHI, ERIWARAWE MAHADURAGE (MD)
Entity Type:Individual
Prefix:
First Name:ERIWARAWE
Middle Name:MAHADURAGE
Last Name:HETTIARACHCHI
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:E.M. MALITHA
Other - Middle Name:SAMANTHIKA
Other - Last Name:HETTIARACHCHI
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:PO BOX 674147
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48267-4147
Mailing Address - Country:US
Mailing Address - Phone:248-354-4709
Mailing Address - Fax:248-354-4807
Practice Address - Street 1:26677 W 12 MILE RD # B6
Practice Address - Street 2:
Practice Address - City:SOUTHFIELD
Practice Address - State:MI
Practice Address - Zip Code:48034-1514
Practice Address - Country:US
Practice Address - Phone:248-354-4709
Practice Address - Fax:248-354-4807
Is Sole Proprietor?:No
Enumeration Date:2011-12-01
Last Update Date:2022-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301092203207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine