Healthcare Provider Details

I. General information

NPI: 1407967821
Provider Name (Legal Business Name): MABODAWILAGE GANGA HEMATILLAKE MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/31/2006
Last Update Date: 07/03/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

650 S ZEDIKER AVE
PARLIER CA
93648
US

IV. Provider business mailing address

650 S ZEDIKER AVE
PARLIER CA
93648-2666
US

V. Phone/Fax

Practice location:
  • Phone: 559-646-3561
  • Fax: 559-646-6617
Mailing address:
  • Phone: 559-646-3561
  • Fax: 559-646-6617

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number379576-1205
License Number StateUT
# 2
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberM8520
License Number StateID
# 3
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberMD428463
License Number StatePA
# 4
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberC149813
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: