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 1:5310 W THUNDERBIRD RD STE 308
Mailing Address - Street 2:
Mailing Address - City:GLENDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85306-4710
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4200 E CAMELBACK RD STE 202
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85018-2718
Practice Address - Country:US
Practice Address - Phone:602-462-0469
Practice Address - Fax:602-635-3846
Is Sole Proprietor?:No
Enumeration Date:2006-11-08
Last Update Date:2025-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101250836207T00000X
AZ54678207T00000X
ORMD26843207T00000X
ORLL15652207T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207T00000XAllopathic & Osteopathic PhysiciansNeurological Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
VAVV4010A696Medicare PIN
VV4010AMedicare PIN
I46160Medicare UPIN