MEDICARE: DR. ITALA MANOSHA WICKREMASINGHE MD

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	2081P0004X	Spinal Cord Injury Medicine Physician	92490	CA

General Provider Information

NPI Number	:	1508972050
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. ITALA MANOSHA WICKREMASINGHE MD

Provider Business Mailing Address
First Line	:	8631 CLOVER MEADOW DR
Second Line	:
City	:	DALLAS
State	:	TX
Zip	:	75243-7626
Country	:	US
Telephone Number	:	214-553-9118
Fax Number	:

Provider Business Practice Location Address
First Line	:	4500 S LANCASTER RD
Second Line	:
City	:	DALLAS
State	:	TX
Zip	:	75216-7167
Country	:	US
Telephone Number	:	214-857-1757
Fax Number	:

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

Provider Enumeration Date	:	08/21/2006
Last Update Date	:	07/08/2007

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