Provider Demographics
NPI:1235148693
Name:DEVASGUNAWARDHANE, ANNESLEY T (MD)
Entity Type:Individual
Prefix:
First Name:ANNESLEY
Middle Name:T
Last Name:DEVASGUNAWARDHANE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:TED
Other - Middle Name:
Other - Last Name:DEVAS
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:102 COMMERCE DR
Mailing Address - Street 2:
Mailing Address - City:CLIFTON
Mailing Address - State:IL
Mailing Address - Zip Code:60927-9501
Mailing Address - Country:US
Mailing Address - Phone:815-694-2381
Mailing Address - Fax:815-694-2256
Practice Address - Street 1:102 COMMERCE DR
Practice Address - Street 2:
Practice Address - City:CLIFTON
Practice Address - State:IL
Practice Address - Zip Code:60927-9501
Practice Address - Country:US
Practice Address - Phone:815-694-2381
Practice Address - Fax:815-694-2256
Is Sole Proprietor?:No
Enumeration Date:2006-08-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036-054736207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036054736Medicaid
IL036054736Medicaid