Provider Demographics
NPI:1053882399
Name:JAYAKODY, WIMAL (PHYSICAL THERAPIST)
Entity type:Individual
Prefix:MR
First Name:WIMAL
Middle Name:
Last Name:JAYAKODY
Suffix:
Gender:M
Credentials:PHYSICAL THERAPIST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1259 AZIZ DR
Mailing Address - Street 2:
Mailing Address - City:CANTON
Mailing Address - State:MI
Mailing Address - Zip Code:48188-5092
Mailing Address - Country:US
Mailing Address - Phone:734-846-7183
Mailing Address - Fax:
Practice Address - Street 1:1259 AZIZ DR
Practice Address - Street 2:
Practice Address - City:CANTON
Practice Address - State:MI
Practice Address - Zip Code:48188-5092
Practice Address - Country:US
Practice Address - Phone:734-846-7183
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-12-16
Last Update Date:2018-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5501005942261QP2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy