Provider Demographics
NPI:1356080782
Name:MAHINDA RAJASOORIYAGE, WATHSALA ERANDATHI (MBBS)
Entity Type:Individual
Prefix:
First Name:WATHSALA ERANDATHI
Middle Name:
Last Name:MAHINDA RAJASOORIYAGE
Suffix:
Gender:F
Credentials:MBBS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:400 S GREENWOOD AVE
Mailing Address - Street 2:
Mailing Address - City:EASTON
Mailing Address - State:PA
Mailing Address - Zip Code:18045-3776
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:400 S GREENWOOD AVE
Practice Address - Street 2:
Practice Address - City:EASTON
Practice Address - State:PA
Practice Address - Zip Code:18045-3776
Practice Address - Country:US
Practice Address - Phone:484-822-5205
Practice Address - Fax:833-214-9836
Is Sole Proprietor?:No
Enumeration Date:2022-06-02
Last Update Date:2022-06-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMT225154207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine