Basic Information
| Provider Information | |||||||||
| NPI: | 1033748702 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MEDAGANGODA | ||||||||
| FirstName: | MITHUN | ||||||||
| MiddleName: | N | ||||||||
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| Credential: | DO | ||||||||
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| Mailing Information | |||||||||
| Address1: | 400 W MINERAL KING AVE | ||||||||
| Address2: | |||||||||
| City: | VISALIA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 932916237 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 4411 E KINGS CANYON RD # 319 | ||||||||
| Address2: | |||||||||
| City: | FRESNO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 937023604 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5596002382 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 04/05/2020 | ||||||||
| LastUpdateDate: | 02/14/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 02/14/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2084P0800X | PTL1706 | CA | N | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Psychiatry | 390200000X | Y | Student, Health Care | Student in an Organized Health Care Education/Training Program |
No ID Information.