Provider Demographics
NPI:1578545182
Name:DISSANAYAKE, MAGHA SIRIMEVAN (MD)
Entity Type:Individual
Prefix:MR
First Name:MAGHA
Middle Name:SIRIMEVAN
Last Name:DISSANAYAKE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Other - Middle Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 1517
Mailing Address - Street 2:
Mailing Address - City:PENDLETON
Mailing Address - State:OR
Mailing Address - Zip Code:97801-0410
Mailing Address - Country:US
Mailing Address - Phone:877-708-1119
Mailing Address - Fax:541-278-8349
Practice Address - Street 1:147 S 52ND PL
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:OR
Practice Address - Zip Code:97478-6210
Practice Address - Country:US
Practice Address - Phone:541-746-1166
Practice Address - Fax:541-393-1607
Is Sole Proprietor?:Yes
Enumeration Date:2005-11-18
Last Update Date:2022-12-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD21258207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR151267Medicaid
G78067Medicare UPIN
OR151267Medicaid
ORR111118Medicare PIN