Healthcare Provider Details

I. General information

NPI: 1801209390
Provider Name (Legal Business Name): NADISHANI THAMALI DISSANAYAKA D.O
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/03/2014
Last Update Date: 07/24/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2301 E. EVESHAM ROAD BLDG 800, SUITE 115
VOORHEES NJ
08043-4509
US

IV. Provider business mailing address

2301 E. EVESHAM ROAD BLDG 800, SUITE 115
VOORHEES NJ
08043-4509
US

V. Phone/Fax

Practice location:
  • Phone: 856-424-5005
  • Fax: 856-424-4716
Mailing address:
  • Phone: 856-424-5005
  • Fax: 856-424-4716

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RR0500X
TaxonomyRheumatology Physician
License Number25MB10538600
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: