Provider Demographics
NPI:1114367356
Name:IDANGODAGE, HASITHA (MD)
Entity Type:Individual
Prefix:
First Name:HASITHA
Middle Name:
Last Name:IDANGODAGE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1201 11TH AVE SW
Mailing Address - Street 2:
Mailing Address - City:MINOT
Mailing Address - State:ND
Mailing Address - Zip Code:58701-4207
Mailing Address - Country:US
Mailing Address - Phone:701-858-6778
Mailing Address - Fax:701-858-6811
Practice Address - Street 1:1201 11TH AVE SW
Practice Address - Street 2:
Practice Address - City:MINOT
Practice Address - State:ND
Practice Address - Zip Code:58701-4207
Practice Address - Country:US
Practice Address - Phone:701-858-6778
Practice Address - Fax:701-858-6811
Is Sole Proprietor?:No
Enumeration Date:2013-07-02
Last Update Date:2013-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NDRL12778207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine