Healthcare Provider Details

I. General information

NPI: 1124321658
Provider Name (Legal Business Name): SURANGA MIHINDU DHARMARATNE MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/06/2010
Last Update Date: 03/17/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1818 N MEADE ST
APPLETON WI
54911-3454
US

IV. Provider business mailing address

130 2ND ST
NEENAH WI
54956-2883
US

V. Phone/Fax

Practice location:
  • Phone: 920-735-7645
  • Fax: 920-735-7618
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208M00000X
TaxonomyHospitalist Physician
License Number2011018947
License Number StateMO
# 2
Primary TaxonomyY
Taxonomy Code208M00000X
TaxonomyHospitalist Physician
License Number64433-20
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: