Provider Demographics
NPI:1720219926
Name:WIJESOORIYA, HIMALI SHESHTRA (MD)
Entity Type:Individual
Prefix:
First Name:HIMALI
Middle Name:SHESHTRA
Last Name:WIJESOORIYA
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 1:640 COURT STREET
Mailing Address - Street 2:
Mailing Address - City:WEST BRANCH
Mailing Address - State:MI
Mailing Address - Zip Code:48661-0001
Mailing Address - Country:US
Mailing Address - Phone:989-345-8120
Mailing Address - Fax:989-345-8129
Practice Address - Street 1:640 COURT STREET
Practice Address - Street 2:
Practice Address - City:WEST BRANCH
Practice Address - State:MI
Practice Address - Zip Code:48661-0001
Practice Address - Country:US
Practice Address - Phone:989-345-8120
Practice Address - Fax:989-345-8129
Is Sole Proprietor?:Yes
Enumeration Date:2009-08-05
Last Update Date:2018-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA10206300207Q00000X
MI4301102341207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine