Basic Information
| Provider Information | |||||||||
| NPI: | 1861493413 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MENDIS | ||||||||
| FirstName: | ROGER | ||||||||
| MiddleName: | EDWARD | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
| OtherOrganizationName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 10470 OLD PLACERVILLE RD | ||||||||
| Address2: | SUITE 100 | ||||||||
| City: | SACRAMENTO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 958272539 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8004700071 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 2725 CAPITOL AVE | ||||||||
| Address2: | SUITE 300 | ||||||||
| City: | SACRAMENTO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 958166004 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9162629370 | ||||||||
| FaxNumber: | 7182629375 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/04/2005 | ||||||||
| LastUpdateDate: | 07/28/2015 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | 03/22/2006 | ||||||||
| NPIReactivationDate: | 03/28/2006 | ||||||||
| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RG0100X | 164935 | NY | N | Allopathic & Osteopathic Physicians | Internal Medicine | Gastroenterology | 207RG0100X | G83502 | CA | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Gastroenterology |
ID Information
| ID | Type | State | Issuer | Description | 01423138 | 05 | NY | MEDICAID |