Provider Demographics
NPI:1497965594
Name:PREMARATNE, RAJITHA L (MD)
Entity Type:Individual
Prefix:
First Name:RAJITHA
Middle Name:L
Last Name:PREMARATNE
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 1:1770 PARK TERRACE AVE
Mailing Address - Street 2:
Mailing Address - City:LAKE HAVASU CITY
Mailing Address - State:AZ
Mailing Address - Zip Code:86404-1055
Mailing Address - Country:US
Mailing Address - Phone:928-680-3861
Mailing Address - Fax:928-680-4256
Practice Address - Street 1:1980 MESQUITE AVE
Practice Address - Street 2:SUITE 103
Practice Address - City:LAKE HAVASU CITY
Practice Address - State:AZ
Practice Address - Zip Code:86403-7713
Practice Address - Country:US
Practice Address - Phone:928-680-4255
Practice Address - Fax:928-680-4256
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-23
Last Update Date:2012-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOMO# 2006014659207R00000X
AZ46348207RR0500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RR0500XAllopathic & Osteopathic PhysiciansInternal MedicineRheumatology
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine