Provider Demographics
NPI:1750510889
Name:DALZELL, LIHINI IMALA (DO)
Entity Type:Individual
Prefix:DR
First Name:LIHINI
Middle Name:IMALA
Last Name:DALZELL
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:LIHINI
Other - Middle Name:IMALA
Other - Last Name:WEERASURIYA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DO
Mailing Address - Street 1:5318 34TH ST W
Mailing Address - Street 2:
Mailing Address - City:BRADENTON
Mailing Address - State:FL
Mailing Address - Zip Code:34210-3401
Mailing Address - Country:US
Mailing Address - Phone:941-758-0205
Mailing Address - Fax:941-758-0132
Practice Address - Street 1:5318 34TH ST W
Practice Address - Street 2:
Practice Address - City:BRADENTON
Practice Address - State:FL
Practice Address - Zip Code:34210-3401
Practice Address - Country:US
Practice Address - Phone:941-758-0205
Practice Address - Fax:941-758-0132
Is Sole Proprietor?:Yes
Enumeration Date:2009-07-10
Last Update Date:2015-04-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOS11114207Q00000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL003883600Medicaid