Provider Demographics
NPI:1306861562
Name:WIJETILLEKE, PADMA P (MD)
Entity Type:Individual
Prefix:
First Name:PADMA
Middle Name:P
Last Name:WIJETILLEKE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:611 S CARLIN SPRINGS RD
Mailing Address - Street 2:SUITE 101
Mailing Address - City:ARLINGTON
Mailing Address - State:VA
Mailing Address - Zip Code:22204-1064
Mailing Address - Country:US
Mailing Address - Phone:703-379-0704
Mailing Address - Fax:703-379-7947
Practice Address - Street 1:611 S CARLIN SPRINGS RD
Practice Address - Street 2:SUITE 101
Practice Address - City:ARLINGTON
Practice Address - State:VA
Practice Address - Zip Code:22204-1064
Practice Address - Country:US
Practice Address - Phone:703-379-0704
Practice Address - Fax:703-379-7947
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101033749174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA006716059Medicaid