Provider Demographics
NPI:1396846390
Name:KULATILAKE, THILI N (MD)
Entity Type:Individual
Prefix:DR
First Name:THILI
Middle Name:N
Last Name:KULATILAKE
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 1:4721 N 1ST AVE
Mailing Address - Street 2:
Mailing Address - City:TUCSON
Mailing Address - State:AZ
Mailing Address - Zip Code:85718-5610
Mailing Address - Country:US
Mailing Address - Phone:520-887-0035
Mailing Address - Fax:520-888-0134
Practice Address - Street 1:4721 N 1ST AVE
Practice Address - Street 2:
Practice Address - City:TUCSON
Practice Address - State:AZ
Practice Address - Zip Code:85718-5610
Practice Address - Country:US
Practice Address - Phone:520-887-0035
Practice Address - Fax:520-888-0134
Is Sole Proprietor?:No
Enumeration Date:2006-09-25
Last Update Date:2008-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ21515207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ1344307004Medicaid
AZZ190924Medicare PIN