Provider Demographics
NPI:1457442113
Name:SOORIARACHCHI, SANJAYA P (MD)
Entity Type:Individual
Prefix:DR
First Name:SANJAYA
Middle Name:P
Last Name:SOORIARACHCHI
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:125 S CLARK ST STE 900
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60603-4043
Mailing Address - Country:US
Mailing Address - Phone:512-988-5355
Mailing Address - Fax:
Practice Address - Street 1:1335 E WHITESTONE BLVD SPC 100
Practice Address - Street 2:
Practice Address - City:CEDAR PARK
Practice Address - State:TX
Practice Address - Zip Code:78613-7598
Practice Address - Country:US
Practice Address - Phone:512-988-5355
Practice Address - Fax:512-465-4841
Is Sole Proprietor?:No
Enumeration Date:2006-09-27
Last Update Date:2023-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXN1158207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX198834703Medicaid
TX262227YLPSOtherWELLMED PTAN
200145OtherBLUE CROSS OF MO
MO207492802Medicaid
TX262227YLPSOtherWELLMED PTAN
TX198834703Medicaid
H86490Medicare UPIN