Provider Demographics
NPI:1659548873
Name:WIJETILLEKE, MEDHINE ANUSHA (MD)
Entity Type:Individual
Prefix:
First Name:MEDHINE
Middle Name:ANUSHA
Last Name:WIJETILLEKE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6287 DUNAWAY CT
Mailing Address - Street 2:
Mailing Address - City:MC LEAN
Mailing Address - State:VA
Mailing Address - Zip Code:22101-2205
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:163 FORT EVANS RD NE
Practice Address - Street 2:
Practice Address - City:LEESBURG
Practice Address - State:VA
Practice Address - Zip Code:20176
Practice Address - Country:US
Practice Address - Phone:703-443-2000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-05-15
Last Update Date:2018-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101244075208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA1659548873Medicaid