Provider Demographics
NPI:1013517028
Name:WICKRAMA, ABHIMANI (MD)
Entity Type:Individual
Prefix:MRS
First Name:ABHIMANI
Middle Name:
Last Name:WICKRAMA
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 1:15720 WOODLAND DR
Mailing Address - Street 2:
Mailing Address - City:DEARBORN
Mailing Address - State:MI
Mailing Address - Zip Code:48120
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:6001 W OUTER DR STE 114
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48235-2626
Practice Address - Country:US
Practice Address - Phone:313-966-9444
Practice Address - Fax:313-966-9418
Is Sole Proprietor?:Yes
Enumeration Date:2020-10-28
Last Update Date:2023-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4351047311390200000X
MI4301508527207R00000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program