Provider Demographics
NPI:1942215330
Name:ROHINI WIJETILLEKE MD PC
Entity Type:Organization
Organization Name:ROHINI WIJETILLEKE MD PC
Other - Org Name:FAMILY PRACTICE AND PEDIATRICS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MD PC
Authorized Official - Prefix:DR
Authorized Official - First Name:ROHINI
Authorized Official - Middle Name:
Authorized Official - Last Name:WIJETILLEKE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:703-471-7733
Mailing Address - Street 1:100 ELDEN STREET
Mailing Address - Street 2:SUITE 14
Mailing Address - City:HERNDON
Mailing Address - State:VA
Mailing Address - Zip Code:20170
Mailing Address - Country:US
Mailing Address - Phone:703-471-7733
Mailing Address - Fax:703-471-7733
Practice Address - Street 1:100 ELDEN STREET
Practice Address - Street 2:SUITE 14
Practice Address - City:HERNDON
Practice Address - State:VA
Practice Address - Zip Code:20170
Practice Address - Country:US
Practice Address - Phone:703-471-7733
Practice Address - Fax:703-471-7733
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-31
Last Update Date:2007-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA35528207Q00000X, 208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Multi-Specialty
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
210923OtherBLUE CROSS BS
VA5618410Medicaid
281178OtherAMERIGROUP
VA6711324Medicaid
VA5618410Medicaid
VA6711324Medicaid