1104974138 NPI number — CHANDANIKA LANKENDRA GUNAWARDANA MD

Table of content: CHANDANIKA LANKENDRA GUNAWARDANA MD (NPI 1104974138)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1104974138 NPI number — CHANDANIKA LANKENDRA GUNAWARDANA MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
GUNAWARDANA
Provider First Name:
CHANDANIKA
Provider Middle Name:
LANKENDRA
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1104974138
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
12/14/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
393 E WALNUT ST
Provider Second Line Business Mailing Address:
3RD FLOOR PHR SYSTEMS
Provider Business Mailing Address City Name:
PASADENA
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
91188-0001
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
--
Provider Business Mailing Address Fax Number:
--

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
441 N LAKEVIEW AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ANAHEIM
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
92807-3028
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
888-988-2800
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
01/08/2007

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 208000000X , with the licence number:  A72289 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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