Provider Demographics
NPI:1407967821
Name:HEMATILLAKE, MABODAWILAGE GANGA (MD)
Entity Type:Individual
Prefix:DR
First Name:MABODAWILAGE
Middle Name:GANGA
Last Name:HEMATILLAKE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Mailing Address - Street 1:650 S ZEDIKER AVE
Mailing Address - Street 2:
Mailing Address - City:PARLIER
Mailing Address - State:CA
Mailing Address - Zip Code:93648-2666
Mailing Address - Country:US
Mailing Address - Phone:559-646-3561
Mailing Address - Fax:559-646-6617
Practice Address - Street 1:650 S ZEDIKER AVE
Practice Address - Street 2:
Practice Address - City:PARLIER
Practice Address - State:CA
Practice Address - Zip Code:93648
Practice Address - Country:US
Practice Address - Phone:559-646-3561
Practice Address - Fax:559-646-6617
Is Sole Proprietor?:No
Enumeration Date:2006-08-31
Last Update Date:2018-07-03
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
UT379576-1205207R00000X
IDM8520207R00000X
PAMD428463207R00000X
CAC149813207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine