Provider Demographics
NPI:1952741464
Name:MABOTUWANA, VENUKA WICKRAMAARACHCHI (MD)
Entity type:Individual
Prefix:DR
First Name:VENUKA
Middle Name:WICKRAMAARACHCHI
Last Name:MABOTUWANA
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Mailing Address - Street 1:15825 SHADY GROVE RD STE 140
Mailing Address - Street 2:
Mailing Address - City:ROCKVILLE
Mailing Address - State:MD
Mailing Address - Zip Code:20850-4015
Mailing Address - Country:US
Mailing Address - Phone:301-869-9776
Mailing Address - Fax:
Practice Address - Street 1:11325 SEVEN LOCKS RD STE 290
Practice Address - Street 2:
Practice Address - City:POTOMAC
Practice Address - State:MD
Practice Address - Zip Code:20854-3235
Practice Address - Country:US
Practice Address - Phone:240-507-5110
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-06-28
Last Update Date:2024-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD60656272207Q00000X
MDD0098501207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA1952741464Medicaid