Provider Demographics
NPI:1639331861
Name:GUNADASA, SUSANTHI (MD, MBBS)
Entity Type:Individual
Prefix:DR
First Name:SUSANTHI
Middle Name:
Last Name:GUNADASA
Suffix:
Gender:F
Credentials:MD, MBBS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:30 PROSPECT AVE
Mailing Address - Street 2:
Mailing Address - City:HACKENSACK
Mailing Address - State:NJ
Mailing Address - Zip Code:07601-1914
Mailing Address - Country:US
Mailing Address - Phone:551-996-1131
Mailing Address - Fax:
Practice Address - Street 1:30 PROSPECT AVE
Practice Address - Street 2:
Practice Address - City:HACKENSACK
Practice Address - State:NJ
Practice Address - Zip Code:07601-1914
Practice Address - Country:US
Practice Address - Phone:551-996-1131
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-06-29
Last Update Date:2013-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA09346600207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine