Healthcare Provider Details

I. General information

NPI: 1740410596
Provider Name (Legal Business Name): EROSHA CHAMINI JAYAWARDENA M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/14/2009
Last Update Date: 10/30/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

303 PARKWAY DR NE
ATLANTA GA
30312-1212
US

IV. Provider business mailing address

303 PARKWAY DR NE
ATLANTA GA
30312-1212
US

V. Phone/Fax

Practice location:
  • Phone: 404-265-4919
  • Fax: 404-265-4989
Mailing address:
  • Phone: 404-265-4919
  • Fax: 404-265-4989

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number068423
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code207RA0000X
TaxonomyAdolescent Medicine (Internal Medicine) Physician
License Number003694
License Number StateGA
# 3
Primary TaxonomyY
Taxonomy Code208M00000X
TaxonomyHospitalist Physician
License Number068423
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: