Provider Demographics
NPI:1437473238
Name:PADMA WIJETILLEKE,MD PC
Entity Type:Organization
Organization Name:PADMA WIJETILLEKE,MD PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:PADMA
Authorized Official - Middle Name:P
Authorized Official - Last Name:WIJETILLEKE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:703-379-0704
Mailing Address - Street 1:611 S CARLIN SPRINGS RD
Mailing Address - Street 2:STE 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:STE 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
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-03-23
Last Update Date:2010-03-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA01010337492080A0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2080A0000XAllopathic & Osteopathic PhysiciansPediatricsAdolescent MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA6716059Medicaid