Healthcare Provider Details

I. General information

NPI: 1497965594
Provider Name (Legal Business Name): RAJITHA L PREMARATNE M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/23/2007
Last Update Date: 08/27/2025
Certification Date: 08/27/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2005 INJO DR STE 102
LAKE HAVASU CITY AZ
86403-5874
US

IV. Provider business mailing address

2005 INJO DR STE 102
LAKE HAVASU CITY AZ
86403-5874
US

V. Phone/Fax

Practice location:
  • Phone: 928-680-4255
  • Fax: 928-680-4256
Mailing address:
  • Phone: 928-680-4255
  • Fax: 928-680-4256

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberMO# 2006014659
License Number StateMO
# 2
Primary TaxonomyY
Taxonomy Code207RR0500X
TaxonomyRheumatology Physician
License Number46348
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: