Provider Demographics
NPI:1023085842
Name:HETTIARACHCHY, RUKMIN R (MD)
Entity type:Individual
Prefix:
First Name:RUKMIN
Middle Name:R
Last Name:HETTIARACHCHY
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 1:500 S UNIVERSITY AVE STE 500
Mailing Address - Street 2:
Mailing Address - City:LITTLE ROCK
Mailing Address - State:AR
Mailing Address - Zip Code:72205-5307
Mailing Address - Country:US
Mailing Address - Phone:501-664-4532
Mailing Address - Fax:501-663-4335
Practice Address - Street 1:300 WERNER ST
Practice Address - Street 2:
Practice Address - City:HOT SPRINGS
Practice Address - State:AR
Practice Address - Zip Code:71913-6406
Practice Address - Country:US
Practice Address - Phone:501-664-4532
Practice Address - Fax:501-663-4335
Is Sole Proprietor?:No
Enumeration Date:2006-03-01
Last Update Date:2020-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ35938207L00000X
ARE-12058207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ231428Medicaid
116390OtherMEDICARE
116390OtherMEDICARE