Provider Demographics
NPI:1982803334
Name:JAYATILLEKA, NIMALKA PANAMULLA (MD)
Entity Type:Individual
Prefix:
First Name:NIMALKA
Middle Name:PANAMULLA
Last Name:JAYATILLEKA
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:621 S ILLINOIS AVE
Mailing Address - Street 2:SUITE 103
Mailing Address - City:MASON CITY
Mailing Address - State:IA
Mailing Address - Zip Code:50401-5489
Mailing Address - Country:US
Mailing Address - Phone:641-428-6900
Mailing Address - Fax:641-428-6909
Practice Address - Street 1:621 S ILLINOIS AVE
Practice Address - Street 2:SUITE 100
Practice Address - City:MASON CITY
Practice Address - State:IA
Practice Address - Zip Code:50401-5489
Practice Address - Country:US
Practice Address - Phone:641-428-6900
Practice Address - Fax:641-428-6909
Is Sole Proprietor?:No
Enumeration Date:2007-07-16
Last Update Date:2019-07-31
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MN103522207Q00000X
IA37444207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MNH400152029Medicare PIN