Provider Demographics
NPI:1578724019
Name:PRASANNA C WICKREMESINGHE MD PC
Entity Type:Organization
Organization Name:PRASANNA C WICKREMESINGHE MD PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:PRASANNA
Authorized Official - Middle Name:C
Authorized Official - Last Name:WICKREMESINGHE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:718-448-0865
Mailing Address - Street 1:481 BARD AVE
Mailing Address - Street 2:
Mailing Address - City:STATEN ISLAND
Mailing Address - State:NY
Mailing Address - Zip Code:10310-2103
Mailing Address - Country:US
Mailing Address - Phone:718-448-0865
Mailing Address - Fax:718-816-8065
Practice Address - Street 1:481 BARD AVE
Practice Address - Street 2:
Practice Address - City:STATEN ISLAND
Practice Address - State:NY
Practice Address - Zip Code:10310-2103
Practice Address - Country:US
Practice Address - Phone:718-448-0865
Practice Address - Fax:718-816-8065
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-06-18
Last Update Date:2008-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYA100000208Medicare PIN