Healthcare Provider Details

I. General information

NPI: 1992994826
Provider Name (Legal Business Name): SISIRA GUNAWARDANE M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/16/2007
Last Update Date: 02/27/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

333 N SUNSET AVE
WEST COVINA CA
91790-1651
US

IV. Provider business mailing address

333 N SUNSET AVE
WEST COVINA CA
91790-1651
US

V. Phone/Fax

Practice location:
  • Phone: 626-960-5461
  • Fax: 626-962-7199
Mailing address:
  • Phone: 626-960-5461
  • Fax: 626-962-7199

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberA33761
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: