Basic Information
| Provider Information | |||||||||
| NPI: | 1659548873 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | WIJETILLEKE | ||||||||
| FirstName: | MEDHINE | ||||||||
| MiddleName: | ANUSHA | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 6287 DUNAWAY CT | ||||||||
| Address2: | |||||||||
| City: | MC LEAN | ||||||||
| State: | VA | ||||||||
| PostalCode: | 221012205 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 163 FORT EVANS RD NE | ||||||||
| Address2: | |||||||||
| City: | LEESBURG | ||||||||
| State: | VA | ||||||||
| PostalCode: | 20176 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7034432000 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 05/15/2008 | ||||||||
| LastUpdateDate: | 12/08/2018 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | 0101244075 | VA | Y | Allopathic & Osteopathic Physicians | Pediatrics |
ID Information
| ID | Type | State | Issuer | Description | 1659548873 | 05 | VA | MEDICAID |