Provider Demographics
NPI:1710056080
Name:ELLEGALA, DILANTHA B (MD)
Entity Type:Individual
Prefix:
First Name:DILANTHA
Middle Name:B
Last Name:ELLEGALA
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 1:1019 VISTA PARK DR STE A
Mailing Address - Street 2:
Mailing Address - City:FOREST
Mailing Address - State:VA
Mailing Address - Zip Code:24551-4901
Mailing Address - Country:US
Mailing Address - Phone:434-200-9009
Mailing Address - Fax:434-200-9005
Practice Address - Street 1:1019 VISTA PARK DR STE A
Practice Address - Street 2:
Practice Address - City:FOREST
Practice Address - State:VA
Practice Address - Zip Code:24551-4901
Practice Address - Country:US
Practice Address - Phone:434-200-9009
Practice Address - Fax:434-200-9005
Is Sole Proprietor?:No
Enumeration Date:2006-11-08
Last Update Date:2016-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORLL15652207T00000X
ORMD26843207T00000X
VA0101250836207T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207T00000XAllopathic & Osteopathic PhysiciansNeurological Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
VAVV4010A696Medicare PIN
VV4010AMedicare PIN
I46160Medicare UPIN