Healthcare Provider Details

I. General information

NPI: 1639286123
Provider Name (Legal Business Name): SHARMILA D DISSANAIKE MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/23/2006
Last Update Date: 02/13/2025
Certification Date: 02/13/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3601 4TH ST # MS 8312
LUBBOCK TX
79430-6340
US

IV. Provider business mailing address

800 BRADBURY DR SE STE 116
ALBUQUERQUE NM
87106-4310
US

V. Phone/Fax

Practice location:
  • Phone: 806-743-2164
  • Fax:
Mailing address:
  • Phone: 505-272-1476
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2086S0102X
TaxonomySurgical Critical Care Physician
License NumberMD2004-0043
License Number StateNM
# 2
Primary TaxonomyY
Taxonomy Code2086S0102X
TaxonomySurgical Critical Care Physician
License NumberM7952
License Number StateTX
# 3
Primary TaxonomyN
Taxonomy Code208600000X
TaxonomySurgery Physician
License NumberM7952
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: