Healthcare Provider Details

I. General information

NPI: 1821056763
Provider Name (Legal Business Name): MAPATUNAGE ANANDA SIRIWARDENA M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/02/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1656 CHAMPLIN AVE
UTICA NY
13502-4830
US

IV. Provider business mailing address

102 STONEBRIDGE CT
NEW HARTFORD NY
13413-5513
US

V. Phone/Fax

Practice location:
  • Phone: 315-624-6944
  • Fax: 315-624-4767
Mailing address:
  • Phone: 315-732-4319
  • Fax: 315-732-4257

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code204C00000X
TaxonomySports Medicine (Neuromusculoskeletal Medicine) Physician
License Number195470
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: