Provider Demographics
NPI:1821058694
Name:WIJETILAKA, ROHAN L (MD)
Entity Type:Individual
Prefix:DR
First Name:ROHAN
Middle Name:L
Last Name:WIJETILAKA
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 1:944 N BROADWAY
Mailing Address - Street 2:SUITE 203
Mailing Address - City:YONKERS
Mailing Address - State:NY
Mailing Address - Zip Code:10701-1304
Mailing Address - Country:US
Mailing Address - Phone:914-963-2484
Mailing Address - Fax:914-963-3674
Practice Address - Street 1:944 N BROADWAY
Practice Address - Street 2:SUITE 203
Practice Address - City:YONKERS
Practice Address - State:NY
Practice Address - Zip Code:10701-1304
Practice Address - Country:US
Practice Address - Phone:914-963-2484
Practice Address - Fax:914-963-3674
Is Sole Proprietor?:Yes
Enumeration Date:2006-03-24
Last Update Date:2008-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY193531207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01663152Medicaid
NY060071266OtherRR MEDICARE ID
NY060071266OtherRR MEDICARE ID
NY01663152Medicaid