Provider Demographics
NPI:1548211832
Name:JAYATILAKE, PRASANI NILWALA (MD)
Entity Type:Individual
Prefix:DR
First Name:PRASANI
Middle Name:NILWALA
Last Name:JAYATILAKE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
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Mailing Address - Street 1:46 N SAGINAW ST
Mailing Address - Street 2:
Mailing Address - City:PONTIAC
Mailing Address - State:MI
Mailing Address - Zip Code:48342-2155
Mailing Address - Country:US
Mailing Address - Phone:248-322-6747
Mailing Address - Fax:248-322-5787
Practice Address - Street 1:46 N SAGINAW ST
Practice Address - Street 2:
Practice Address - City:PONTIAC
Practice Address - State:MI
Practice Address - Zip Code:48342-2155
Practice Address - Country:US
Practice Address - Phone:248-322-6747
Practice Address - Fax:248-322-5787
Is Sole Proprietor?:No
Enumeration Date:2006-05-12
Last Update Date:2011-08-30
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MI4301075100207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4473553Medicaid
MI4473553Medicaid
H78049Medicare UPIN