Provider Demographics
NPI:1912958299
Name:JAYATILAKE, HARSHA PERERA (MD)
Entity Type:Individual
Prefix:
First Name:HARSHA
Middle Name:PERERA
Last Name:JAYATILAKE
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 1:37663 PEMBROKE AVE
Mailing Address - Street 2:
Mailing Address - City:LIVONIA
Mailing Address - State:MI
Mailing Address - Zip Code:48152-1050
Mailing Address - Country:US
Mailing Address - Phone:734-591-1300
Mailing Address - Fax:734-591-1344
Practice Address - Street 1:37663 PEMBROKE AVE
Practice Address - Street 2:
Practice Address - City:LIVONIA
Practice Address - State:MI
Practice Address - Zip Code:48152-1050
Practice Address - Country:US
Practice Address - Phone:743-591-1300
Practice Address - Fax:734-591-1344
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-12
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301062267207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4383133Medicaid
BJ4665886OtherDEA
G54159Medicare UPIN
BJ4665886OtherDEA