Provider Demographics
NPI:1821042557
Name:SIRISENA, OMATTA M (MD)
Entity Type:Individual
Prefix:DR
First Name:OMATTA
Middle Name:M
Last Name:SIRISENA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:117 FOY DR
Mailing Address - Street 2:
Mailing Address - City:ROCKY MOUNT
Mailing Address - State:NC
Mailing Address - Zip Code:27804-2418
Mailing Address - Country:US
Mailing Address - Phone:252-443-7678
Mailing Address - Fax:252-443-7147
Practice Address - Street 1:117 FOY DR
Practice Address - Street 2:
Practice Address - City:ROCKY MOUNT
Practice Address - State:NC
Practice Address - Zip Code:27804-2418
Practice Address - Country:US
Practice Address - Phone:252-443-7678
Practice Address - Fax:252-443-7147
Is Sole Proprietor?:No
Enumeration Date:2006-05-19
Last Update Date:2014-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC19771207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC0149COtherBLUE CROSS BLUE SHEILD
NCCL1963OtherRAILROAD MEDICARE
NC890149CMedicaid
NCC86475Medicare UPIN
NC230339Medicare ID - Type Unspecified