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General NPI Number Information
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NPI Number | 1811065204
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Entity Type | Organization
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Legal Business Name | SUNIL M. DISSANAYAKE MD A PROFESSIONAL CORPORATION
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Dates
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Enumeration Date | 12/01/2006
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Last Update Date | 05/14/2008
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Provider Practice Location Address
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Address Line | 1612 NOGALES ST
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City | ROWLAND HEIGHTS
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State | CA
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Zip | 91748-2257
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Country | US
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Telephone | 626-965-1646
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Fax | 626-965-4697
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Provider Business Mailing Address
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Address Line | 1612 NOGALES ST
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City | ROWLAND HEIGHTS
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State | CA
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Zip | 91748-2257
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Country | US
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Telephone | 626-965-1646
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Fax | 626-965-4697
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Authorized Official
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Title or Position | PRESIDENT
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Name | DR. SUNIL MAHANAMA DISSANAYAKE
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Credential | M.D.
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Telephone | 626-965-1646
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207Q00000X
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Taxonomy Name | Family Medicine Physician
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License Number | A39447
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License Number State | CA
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