Provider Demographics
NPI:1457308645
Name:WIJETUNGA, MEVAN NANDAKA (MD)
Entity Type:Individual
Prefix:
First Name:MEVAN
Middle Name:NANDAKA
Last Name:WIJETUNGA
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 1:2401 DEMERS AVE
Mailing Address - Street 2:
Mailing Address - City:GRAND FORKS
Mailing Address - State:ND
Mailing Address - Zip Code:58201
Mailing Address - Country:US
Mailing Address - Phone:701-780-1891
Mailing Address - Fax:
Practice Address - Street 1:1300 S COLUMBIA RD
Practice Address - Street 2:
Practice Address - City:GRAND FORKS
Practice Address - State:ND
Practice Address - Zip Code:58201
Practice Address - Country:US
Practice Address - Phone:701-780-6236
Practice Address - Fax:701-780-6221
Is Sole Proprietor?:No
Enumeration Date:2006-05-31
Last Update Date:2020-12-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN48798207R00000X, 207RC0000X, 207RC0001X
DCMDE33460207RC0000X
ND11101207RC0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0001XAllopathic & Osteopathic PhysiciansInternal MedicineClinical Cardiac Electrophysiology
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA15880581Medicaid
DC034425200Medicaid
MN967611200Medicaid
MD400766200Medicaid
VA15880581Medicaid
MN060002304Medicare PIN
NDN715568Medicare PIN
DC010761C34Medicare ID - Type Unspecified
MN967611200Medicaid
DCH66100Medicare UPIN
DC110247155Medicare ID - Type UnspecifiedRAILROAD