Provider Demographics
NPI:1568570679
Name:WIJAYARATNE, MADHAVI (MD)
Entity Type:Individual
Prefix:DR
First Name:MADHAVI
Middle Name:
Last Name:WIJAYARATNE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:DR
Other - First Name:LIYANAMAHADURA
Other - Middle Name:MADHAVI
Other - Last Name:WIJAYARATNE
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:10 SPRUCE HOLLOW ROAD
Mailing Address - Street 2:
Mailing Address - City:GREEN BROOK
Mailing Address - State:NJ
Mailing Address - Zip Code:08812-1837
Mailing Address - Country:US
Mailing Address - Phone:732-564-9774
Mailing Address - Fax:
Practice Address - Street 1:10 SPRUCE HOLLOW RD
Practice Address - Street 2:
Practice Address - City:GREEN BROOK
Practice Address - State:NJ
Practice Address - Zip Code:08812-1837
Practice Address - Country:US
Practice Address - Phone:732-564-9774
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-28
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJMA59538208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ6247806Medicaid