Healthcare Provider Details

I. General information

NPI: 1114157518
Provider Name (Legal Business Name): SEEDUWA MUDIYANS OWADINI WATHSALA BANDARA MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: OWADINI WATHSALA BANDARA M.D.

II. Dates (important events)

Enumeration Date: 07/20/2009
Last Update Date: 09/16/2021
Certification Date: 09/16/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

514 N PROSPECT AVE
REDONDO BEACH CA
90277-3036
US

IV. Provider business mailing address

5767 W CENTURY BLVD STE 400
LOS ANGELES CA
90045-5631
US

V. Phone/Fax

Practice location:
  • Phone: 310-937-8555
  • Fax:
Mailing address:
  • Phone: 310-301-8771
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberTRL11286
License Number StateND
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberA144138
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: