Provider Demographics
NPI:1417644881
Name:JAYAWARDENA, RUVINI GOONATHILAKE (MD)
Entity Type:Individual
Prefix:
First Name:RUVINI
Middle Name:GOONATHILAKE
Last Name:JAYAWARDENA
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:MASTIYAGE
Other - Middle Name:D RUVINI
Other - Last Name:GOONATHILAKE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:430 N CALDWELL ST APT 105
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28202-2573
Mailing Address - Country:US
Mailing Address - Phone:704-780-7695
Mailing Address - Fax:
Practice Address - Street 1:3901 BEAUBIEN BLVD.
Practice Address - Street 2:3T72 PEDIATRIC EDUCATION OFFICE
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48201-2119
Practice Address - Country:US
Practice Address - Phone:313-745-5533
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-04-18
Last Update Date:2023-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program