Provider Demographics
NPI:1699743096
Name:HETTIARACHCHY, GNANIN JOSEPH (MD)
Entity type:Individual
Prefix:
First Name:GNANIN
Middle Name:JOSEPH
Last Name:HETTIARACHCHY
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:JOSEPH
Other - Middle Name:
Other - Last Name:HETTIARACHCHY
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:PO BOX 820
Mailing Address - Street 2:
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80901-0820
Mailing Address - Country:US
Mailing Address - Phone:719-448-0981
Mailing Address - Fax:719-448-0767
Practice Address - Street 1:6001 E WOODMEN RD
Practice Address - Street 2:
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80923-2601
Practice Address - Country:US
Practice Address - Phone:719-776-5000
Practice Address - Fax:719-448-0767
Is Sole Proprietor?:No
Enumeration Date:2006-03-10
Last Update Date:2011-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO41119207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO69025568Medicaid
COC504288Medicare PIN
CO69025568Medicaid