Provider Demographics
NPI:1871779496
Name:WIJETILLEKE, ROHINI (MD)
Entity type:Individual
Prefix:DR
First Name:ROHINI
Middle Name:
Last Name:WIJETILLEKE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:100 ELDEN ST
Mailing Address - Street 2:SUITE 14
Mailing Address - City:HERNDON
Mailing Address - State:VA
Mailing Address - Zip Code:20170-4873
Mailing Address - Country:US
Mailing Address - Phone:703-471-7733
Mailing Address - Fax:
Practice Address - Street 1:100 ELDEN ST
Practice Address - Street 2:SUITE 14
Practice Address - City:HERNDON
Practice Address - State:VA
Practice Address - Zip Code:20170-4873
Practice Address - Country:US
Practice Address - Phone:703-471-7733
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-01-14
Last Update Date:2008-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA35528207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA478659Medicare PIN