Provider Demographics
NPI:1790705671
Name:ALWIS, MIKEL ANGELO (MD)
Entity Type:Individual
Prefix:
First Name:MIKEL
Middle Name:ANGELO
Last Name:ALWIS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:MAITHRI
Other - Middle Name:N
Other - Last Name:WEERASINGHE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:PO BOX 487
Mailing Address - Street 2:
Mailing Address - City:BARSTOW
Mailing Address - State:CA
Mailing Address - Zip Code:92312-0487
Mailing Address - Country:US
Mailing Address - Phone:760-256-6426
Mailing Address - Fax:
Practice Address - Street 1:716 E MAIN ST
Practice Address - Street 2:
Practice Address - City:BARSTOW
Practice Address - State:CA
Practice Address - Zip Code:92311-2354
Practice Address - Country:US
Practice Address - Phone:760-256-6426
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA48518207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAA048518Medicare UPIN