MEDICARE: DILANTHA B. ELLEGALA MD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207T00000X	Neurological Surgery Physician	0101250836	VA
2	207T00000X	Neurological Surgery Physician	54678	AZ
3	207T00000X	Neurological Surgery Physician	MD26843	OR
4	207T00000X	Neurological Surgery Physician	LL15652	OR

General Provider Information

NPI Number	:	1710056080
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DILANTHA B. ELLEGALA MD

Provider Business Mailing Address
First Line	:	5310 W THUNDERBIRD RD STE 308
Second Line	:
City	:	GLENDALE
State	:	AZ
Zip	:	85306-4710
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	4200 E CAMELBACK RD STE 202
Second Line	:
City	:	PHOENIX
State	:	AZ
Zip	:	85018-2718
Country	:	US
Telephone Number	:	602-462-0469
Fax Number	:	602-635-3846

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	11/08/2006
Last Update Date	:	04/09/2025

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