Provider Demographics
NPI:1659143337
Name:RATHNAYAKE MUDIYANSELAGE, KASUN BUDDHIKA I
Entity Type:Individual
Prefix:MR
First Name:KASUN
Middle Name:BUDDHIKA
Last Name:RATHNAYAKE MUDIYANSELAGE
Suffix:I
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:112 STEWART AVENUE EXT APT 4
Mailing Address - Street 2:
Mailing Address - City:NEWBURGH
Mailing Address - State:NY
Mailing Address - Zip Code:12550-6626
Mailing Address - Country:US
Mailing Address - Phone:845-541-7082
Mailing Address - Fax:
Practice Address - Street 1:112 STEWART AVENUE EXT APT 4
Practice Address - Street 2:
Practice Address - City:NEWBURGH
Practice Address - State:NY
Practice Address - Zip Code:12550-6626
Practice Address - Country:US
Practice Address - Phone:845-541-7082
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-10-25
Last Update Date:2023-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care