Healthcare Provider Details

I. General information

NPI: 1629235403
Provider Name (Legal Business Name): TIKIRI RATNAYAKE M.D., INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/20/2008
Last Update Date: 08/28/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1910 CALUMET AVE
VALPARAISO IN
46383-2704
US

IV. Provider business mailing address

PO BOX 1249
VALPARAISO IN
46384-1249
US

V. Phone/Fax

Practice location:
  • Phone: 219-464-8115
  • Fax:
Mailing address:
  • Phone: 219-464-8115
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QH0100X
TaxonomyHealth Service Clinic/Center
License NumberIN01028333
License Number StateIN

VIII. Authorized Official

Name: HAROON NAZ
Title or Position: CEO
Credential:
Phone: 219-756-2100