Provider Demographics
NPI:1114157518
Name:BANDARA, SEEDUWA MUDIYANS OWADINI WATHSALA (MD)
Entity Type:Individual
Prefix:DR
First Name:SEEDUWA MUDIYANS
Middle Name:OWADINI WATHSALA
Last Name:BANDARA
Suffix:
Gender:F
Credentials:MD
Other - Prefix:DR
Other - First Name:OWADINI
Other - Middle Name:WATHSALA
Other - Last Name:BANDARA
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:5767 W CENTURY BLVD STE 400
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90045-5631
Mailing Address - Country:US
Mailing Address - Phone:310-301-8771
Mailing Address - Fax:
Practice Address - Street 1:514 N PROSPECT AVE
Practice Address - Street 2:
Practice Address - City:REDONDO BEACH
Practice Address - State:CA
Practice Address - Zip Code:90277-3036
Practice Address - Country:US
Practice Address - Phone:310-937-8555
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-07-20
Last Update Date:2021-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NDTRL11286207Q00000X
CAA144138207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine