Healthcare Provider Details

I. General information

NPI: 1336179381
Provider Name (Legal Business Name): MADUWEGEDARA ARIYASINGHE WICKRAMAARATCHI D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

Provider Other Name: M ARI WICKRAMAARATCHI D.O.

II. Dates (important events)

Enumeration Date: 07/04/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

300 CENTER DR RIVERHEAD HEALTH CENTER
RIVERHEAD NY
11901-3393
US

IV. Provider business mailing address

3 ESPLANADE DR
EAST PATCHOGUE NY
11772-7905
US

V. Phone/Fax

Practice location:
  • Phone: 631-852-1818
  • Fax: 631-852-3723
Mailing address:
  • Phone: 631-758-6773
  • Fax: 631-852-3723

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number204613
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: