Provider Demographics
NPI:1437150570
Name:NANAYAKKARA, BERTRAM H (MD FAAP)
Entity Type:Individual
Prefix:
First Name:BERTRAM
Middle Name:H
Last Name:NANAYAKKARA
Suffix:
Gender:M
Credentials:MD FAAP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1567
Mailing Address - Street 2:
Mailing Address - City:ROCKFORD
Mailing Address - State:IL
Mailing Address - Zip Code:61110-0067
Mailing Address - Country:US
Mailing Address - Phone:779-696-7150
Mailing Address - Fax:
Practice Address - Street 1:5695 STRATHMOOR DR
Practice Address - Street 2:SUITE 3
Practice Address - City:ROCKFORD
Practice Address - State:IL
Practice Address - Zip Code:61107-5192
Practice Address - Country:US
Practice Address - Phone:779-696-1150
Practice Address - Fax:815-397-0043
Is Sole Proprietor?:No
Enumeration Date:2005-08-10
Last Update Date:2016-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036-067957208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036067957Medicaid