Provider Demographics
NPI:1265453245
Name:GUNAWARDENE, ISHAN A (MD)
Entity Type:Individual
Prefix:DR
First Name:ISHAN
Middle Name:A
Last Name:GUNAWARDENE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3347 STATE ROAD 7
Mailing Address - Street 2:SUITE-206
Mailing Address - City:WELLINGTON
Mailing Address - State:FL
Mailing Address - Zip Code:33467-0000
Mailing Address - Country:US
Mailing Address - Phone:561-537-4820
Mailing Address - Fax:561-434-3169
Practice Address - Street 1:3347 STATE ROAD 7
Practice Address - Street 2:SUITE-206
Practice Address - City:WELLINGTON
Practice Address - State:FL
Practice Address - Zip Code:33467-0000
Practice Address - Country:US
Practice Address - Phone:561-537-4820
Practice Address - Fax:561-434-3169
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-22
Last Update Date:2010-10-14
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
FLME81674207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL260777800Medicaid
FLG18512Medicare UPIN
FL260777800Medicaid