Healthcare Provider Details

I. General information

NPI: 1699715979
Provider Name (Legal Business Name): MOHANLAL WICKRAMASINGHE MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/07/2006
Last Update Date: 06/07/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3450 S ARCHER AVE
CHICAGO IL
60608-6837
US

IV. Provider business mailing address

3450 S ARCHER AVE
CHICAGO IL
60608-6837
US

V. Phone/Fax

Practice location:
  • Phone: 773-523-1000
  • Fax: 773-843-1553
Mailing address:
  • Phone: 773-523-1000
  • Fax: 773-843-1553

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number036-047140
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: