Provider Demographics
NPI:1609435395
Name:MIRIHAGALLE, NOUPAMA NETHMINI (MD)
Entity Type:Individual
Prefix:
First Name:NOUPAMA
Middle Name:NETHMINI
Last Name:MIRIHAGALLE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:611 W. PARK ST
Mailing Address - Street 2:FAPC
Mailing Address - City:URBANA
Mailing Address - State:IL
Mailing Address - Zip Code:61801
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:611 W PARK ST
Practice Address - Street 2:
Practice Address - City:URBANA
Practice Address - State:IL
Practice Address - Zip Code:61801-2501
Practice Address - Country:US
Practice Address - Phone:217-383-3129
Practice Address - Fax:217-326-1550
Is Sole Proprietor?:No
Enumeration Date:2019-06-06
Last Update Date:2024-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL125073857207R00000X
IL036.160072207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine