Provider Demographics
NPI:1043507833
Name:JAYASURIYA, HARSHINI A (MD)
Entity type:Individual
Prefix:DR
First Name:HARSHINI
Middle Name:A
Last Name:JAYASURIYA
Suffix:
Gender:F
Credentials:MD
Other - Prefix:DR
Other - First Name:HERSHEY
Other - Middle Name:
Other - Last Name:JAYASURIYA
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:PO BOX 639295 DEPT 93394
Mailing Address - Street 2:
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45263-9295
Mailing Address - Country:US
Mailing Address - Phone:248-266-4200
Mailing Address - Fax:855-618-6655
Practice Address - Street 1:2205 JOLLY RD STE B
Practice Address - Street 2:
Practice Address - City:OKEMOS
Practice Address - State:MI
Practice Address - Zip Code:48864-3983
Practice Address - Country:US
Practice Address - Phone:517-347-4085
Practice Address - Fax:517-347-4170
Is Sole Proprietor?:Yes
Enumeration Date:2011-06-30
Last Update Date:2025-01-22
Deactivation Date:2023-02-14
Deactivation Code:
Reactivation Date:2023-02-27
Provider Licenses
StateLicense IDTaxonomies
IL036.167374207Q00000X
IN01091856A207Q00000X
NMMD2024-0792207Q00000X
FLTPME6793207Q00000X
OH35C.000284207Q00000X
MI4301098352207Q00000X
WI3581-320207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty