Healthcare Provider Details

I. General information

NPI: 1861925653
Provider Name (Legal Business Name): VIDUSHANI SRIYANKA PERERA M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/07/2017
Last Update Date: 11/13/2023
Certification Date: 11/13/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

250 E SUPERIOR ST STE 4-2304
CHICAGO IL
60611-2914
US

IV. Provider business mailing address

PO BOX 980615
RICHMOND VA
23298-0615
US

V. Phone/Fax

Practice location:
  • Phone: 312-695-5753
  • Fax: 312-695-5645
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number125077249
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number0116031528
License Number StateVA
# 3
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number036163937
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: