MEDICARE: DR. JESICA MALI SIRIWARDANE O.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	152W00000X	Optometrist	OPT.0003101	CO

General Provider Information

NPI Number	:	1013311851
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. JESICA MALI SIRIWARDANE O.D.

Provider Business Mailing Address
First Line	:	2720 COUNCIL TREE AVE STE 148
Second Line	:
City	:	FORT COLLINS
State	:	CO
Zip	:	80525-6309
Country	:	US
Telephone Number	:	970-530-3097
Fax Number	:

Provider Business Practice Location Address
First Line	:	2720 COUNCIL TREE AVE STE 148
Second Line	:
City	:	FORT COLLINS
State	:	CO
Zip	:	80525-6309
Country	:	US
Telephone Number	:	970-530-3097
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	10/21/2014
Last Update Date	:	10/21/2014

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