Provider Demographics
NPI:1720274921
Name:GUNAWARDANA, GIMHA SUDHANI (MD)
Entity Type:Individual
Prefix:
First Name:GIMHA
Middle Name:SUDHANI
Last Name:GUNAWARDANA
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1010 CASCADE PL
Mailing Address - Street 2:
Mailing Address - City:CLAREMONT
Mailing Address - State:CA
Mailing Address - Zip Code:91711-2525
Mailing Address - Country:US
Mailing Address - Phone:909-965-1215
Mailing Address - Fax:
Practice Address - Street 1:255 E BONITA AVE
Practice Address - Street 2:#101
Practice Address - City:POMONA
Practice Address - State:CA
Practice Address - Zip Code:91767-1923
Practice Address - Country:US
Practice Address - Phone:909-924-1940
Practice Address - Fax:909-924-1943
Is Sole Proprietor?:Yes
Enumeration Date:2007-09-20
Last Update Date:2015-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA101531207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAA101531OtherLICENSE #