Provider Demographics
NPI:1245263623
Name:WIJAY-SAMARASINHA, SHIRANI DAMAYANTHI (MD)
Entity type:Individual
Prefix:DR
First Name:SHIRANI
Middle Name:DAMAYANTHI
Last Name:WIJAY-SAMARASINHA
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 1626
Mailing Address - Street 2:
Mailing Address - City:PORTAGE
Mailing Address - State:MI
Mailing Address - Zip Code:49081-1626
Mailing Address - Country:US
Mailing Address - Phone:269-343-4700
Mailing Address - Fax:269-343-3002
Practice Address - Street 1:5829 S WESTNEDGE AVE
Practice Address - Street 2:
Practice Address - City:PORTAGE
Practice Address - State:MI
Practice Address - Zip Code:49002-1456
Practice Address - Country:US
Practice Address - Phone:269-343-4700
Practice Address - Fax:269-343-3002
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MI4301041041207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIE12099Medicare UPIN