Provider Demographics
NPI:1336179381
Name:WICKRAMAARATCHI, MADUWEGEDARA ARIYASINGHE (DO)
Entity Type:Individual
Prefix:DR
First Name:MADUWEGEDARA
Middle Name:ARIYASINGHE
Last Name:WICKRAMAARATCHI
Suffix:
Gender:M
Credentials:DO
Other - Prefix:DR
Other - First Name:M
Other - Middle Name:ARI
Other - Last Name:WICKRAMAARATCHI
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:DO
Mailing Address - Street 1:3 ESPLANADE DR
Mailing Address - Street 2:
Mailing Address - City:EAST PATCHOGUE
Mailing Address - State:NY
Mailing Address - Zip Code:11772-7905
Mailing Address - Country:US
Mailing Address - Phone:631-758-6773
Mailing Address - Fax:631-852-3723
Practice Address - Street 1:300 CENTER DR
Practice Address - Street 2:RIVERHEAD HEALTH CENTER
Practice Address - City:RIVERHEAD
Practice Address - State:NY
Practice Address - Zip Code:11901-3393
Practice Address - Country:US
Practice Address - Phone:631-852-1818
Practice Address - Fax:631-852-3723
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY204613207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY1805430Medicaid
NYG55284Medicare UPIN
NY1805430Medicaid