Provider Demographics
NPI:1588198873
Name:IDDAWELA, DINITHI KETAGODA (MD)
Entity type:Individual
Prefix:DR
First Name:DINITHI
Middle Name:KETAGODA
Last Name:IDDAWELA
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:DINITHI
Other - Middle Name:MEDAWI
Other - Last Name:KETAGODA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:155 N FRESNO ST
Mailing Address - Street 2:
Mailing Address - City:FRESNO
Mailing Address - State:CA
Mailing Address - Zip Code:93701-2302
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:10535 HOSPITAL WAY
Practice Address - Street 2:
Practice Address - City:MATHER
Practice Address - State:CA
Practice Address - Zip Code:95655-4200
Practice Address - Country:US
Practice Address - Phone:916-843-9391
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-04-13
Last Update Date:2024-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA164758207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine