Provider Demographics
NPI:1861493413
Name:MENDIS, ROGER EDWARD (MD)
Entity type:Individual
Prefix:DR
First Name:ROGER
Middle Name:EDWARD
Last Name:MENDIS
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 1:10470 OLD PLACERVILLE RD
Mailing Address - Street 2:SUITE 100
Mailing Address - City:SACRAMENTO
Mailing Address - State:CA
Mailing Address - Zip Code:95827-2539
Mailing Address - Country:US
Mailing Address - Phone:800-470-0071
Mailing Address - Fax:
Practice Address - Street 1:2725 CAPITOL AVE
Practice Address - Street 2:SUITE 300
Practice Address - City:SACRAMENTO
Practice Address - State:CA
Practice Address - Zip Code:95816-6004
Practice Address - Country:US
Practice Address - Phone:916-262-9370
Practice Address - Fax:718-262-9375
Is Sole Proprietor?:No
Enumeration Date:2005-08-04
Last Update Date:2015-07-28
Deactivation Date:2006-03-22
Deactivation Code:
Reactivation Date:2006-03-28
Provider Licenses
StateLicense IDTaxonomies
NY164935207RG0100X
CAG83502207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01423138Medicaid
F58437Medicare UPIN
NY01423138Medicaid