Provider Demographics
NPI:1265557953
Name:JAYATILAKA, SURESH GEHAN (MD)
Entity type:Individual
Prefix:
First Name:SURESH
Middle Name:GEHAN
Last Name:JAYATILAKA
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 1:503 RIDGE RD
Mailing Address - Street 2:
Mailing Address - City:ROXBORO
Mailing Address - State:NC
Mailing Address - Zip Code:27573-4627
Mailing Address - Country:US
Mailing Address - Phone:336-503-5757
Mailing Address - Fax:336-322-4350
Practice Address - Street 1:1129 N MAIN ST STE G
Practice Address - Street 2:
Practice Address - City:SOUTH BOSTON
Practice Address - State:VA
Practice Address - Zip Code:24592-2547
Practice Address - Country:US
Practice Address - Phone:434-572-8196
Practice Address - Fax:434-572-8341
Is Sole Proprietor?:No
Enumeration Date:2007-03-20
Last Update Date:2022-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101241180207RG0100X
NC2011-00253207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC1265557953Medicaid