Healthcare Provider Details

I. General information

NPI: 1780333567
Provider Name (Legal Business Name): DEEMANTHA GAYAN FERNANDO WIJEKULASOORIYAGE MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/21/2022
Last Update Date: 07/14/2026
Certification Date: 07/14/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

550 UNIVERSITY BLVD # UH2440
INDIANAPOLIS IN
46202-5149
US

IV. Provider business mailing address

550 UNIVERSITY BLVD # UH2440
INDIANAPOLIS IN
46202-5149
US

V. Phone/Fax

Practice location:
  • Phone: 317-274-2018
  • Fax: 317-948-7454
Mailing address:
  • Phone: 317-274-2018
  • Fax: 317-948-7454

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 State
# 2
Primary TaxonomyY
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number01099318A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: