Healthcare Provider Details

I. General information

NPI: 1629658802
Provider Name (Legal Business Name): TDMD PRIMARY CARE PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/12/2021
Last Update Date: 04/17/2021
Certification Date: 04/17/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1001 PEMBERTON HILL RD STE 202
APEX NC
27502-4265
US

IV. Provider business mailing address

1100 S ALODIE CT
APEX NC
27502-5235
US

V. Phone/Fax

Practice location:
  • Phone: 919-760-5228
  • Fax:
Mailing address:
  • Phone: 919-760-5228
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QP2300X
TaxonomyPrimary Care Clinic/Center
License Number
License Number State

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name: DR. THUSITHA R DISSANAYAKE
Title or Position: OWNER/MANAGING MEMEBER
Credential: MD
Phone: 919-760-5228