Provider Demographics
NPI:1295796969
Name:DISSANAYAKE, IMARA R (MD)
Entity type:Individual
Prefix:DR
First Name:IMARA
Middle Name:R
Last Name:DISSANAYAKE
Suffix:
Gender:F
Credentials:MD
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Mailing Address - Street 1:101 EAST OLNEY AVE
Mailing Address - Street 2:STE 400
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19120
Mailing Address - Country:US
Mailing Address - Phone:215-456-7000
Mailing Address - Fax:215-254-2599
Practice Address - Street 1:5501 OLD YORK RD
Practice Address - Street 2:
Practice Address - City:PHILA
Practice Address - State:PA
Practice Address - Zip Code:19144
Practice Address - Country:US
Practice Address - Phone:215-456-6970
Practice Address - Fax:215-456-7154
Is Sole Proprietor?:No
Enumeration Date:2006-03-31
Last Update Date:2011-12-09
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Provider Licenses
StateLicense IDTaxonomies
PAMD072898L207RN0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA001866922Medicaid
H49360Medicare UPIN
PA001866922Medicaid