Provider Demographics
NPI:1942290093
Name:DISSANAYAKE, SUNIL M (MD)
Entity Type:Individual
Prefix:DR
First Name:SUNIL
Middle Name:M
Last Name:DISSANAYAKE
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 1:1612 NOGALES ST
Mailing Address - Street 2:
Mailing Address - City:ROWLAND HEIGHTS
Mailing Address - State:CA
Mailing Address - Zip Code:91748-2257
Mailing Address - Country:US
Mailing Address - Phone:626-965-1646
Mailing Address - Fax:626-965-4697
Practice Address - Street 1:1612 NOGALES ST
Practice Address - Street 2:
Practice Address - City:ROWLAND HEIGHTS
Practice Address - State:CA
Practice Address - Zip Code:91748-2257
Practice Address - Country:US
Practice Address - Phone:626-965-1646
Practice Address - Fax:626-965-4697
Is Sole Proprietor?:No
Enumeration Date:2005-10-27
Last Update Date:2008-12-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA 39447207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
HA39447AOtherMEDICARE PIN #2
CA00A394470Medicaid
AO763ZOtherMEDICARE PIN #3
HA39447AOtherMEDICARE PIN #2
CAA 85288Medicare UPIN