Provider Demographics
NPI:1295896173
Name:SAMARAWEERA, MOHIN TISSA (MD)
Entity type:Individual
Prefix:DR
First Name:MOHIN
Middle Name:TISSA
Last Name:SAMARAWEERA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Other - Credentials:
Mailing Address - Street 1:24016 W MAIN STREET
Mailing Address - Street 2:
Mailing Address - City:PLAINFIELD
Mailing Address - State:IL
Mailing Address - Zip Code:60544
Mailing Address - Country:US
Mailing Address - Phone:815-436-7303
Mailing Address - Fax:815-609-7980
Practice Address - Street 1:24016 W MAIN STREET
Practice Address - Street 2:
Practice Address - City:PLAINFIELD
Practice Address - State:IL
Practice Address - Zip Code:60544
Practice Address - Country:US
Practice Address - Phone:815-436-7303
Practice Address - Fax:815-609-7980
Is Sole Proprietor?:No
Enumeration Date:2006-12-13
Last Update Date:2009-12-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL36048836207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL03L048836Medicaid
IL9900490OtherBC BS
IL9900490OtherBC BS
IL208665Medicare PIN