Provider Demographics
NPI:1225009343
Name:BANDARA, ANURA (PT)
Entity Type:Individual
Prefix:
First Name:ANURA
Middle Name:
Last Name:BANDARA
Suffix:
Gender:M
Credentials:PT
Other - Prefix:MR
Other - First Name:AMBAKKE
Other - Middle Name:
Other - Last Name:BANDARA
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:PT
Mailing Address - Street 1:8107 167TH PL
Mailing Address - Street 2:
Mailing Address - City:TINLEY PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60477-2330
Mailing Address - Country:US
Mailing Address - Phone:708-614-7622
Mailing Address - Fax:
Practice Address - Street 1:16532 OAK PARK AVE
Practice Address - Street 2:SUITE 100
Practice Address - City:TINLEY PARK
Practice Address - State:IL
Practice Address - Zip Code:60477-1918
Practice Address - Country:US
Practice Address - Phone:708-704-4668
Practice Address - Fax:708-532-0030
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-01-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL211647Medicare ID - Type Unspecified