Healthcare Provider Details

I. General information

NPI: 1629463864
Provider Name (Legal Business Name): INOKA ABEYSIRI DEVAPRIYA MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: MISS INOKA ABEYSIRI SAMARASEKARA

II. Dates (important events)

Enumeration Date: 04/04/2015
Last Update Date: 03/17/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 MYRTLE BLVD 103B
GRACEWOOD GA
30812
US

IV. Provider business mailing address

100 MYRTLE BLVD 103B
GRACEWOOD GA
30812
US

V. Phone/Fax

Practice location:
  • Phone: 706-790-2011
  • Fax:
Mailing address:
  • Phone: 706-790-2011
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code208600000X
TaxonomySurgery Physician
License NumberMT208551
License Number StatePA
# 3
Primary TaxonomyY
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number077723
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: