Healthcare Provider Details

I. General information

NPI: 1164929089
Provider Name (Legal Business Name): NAOMI GUNAWARDENA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/08/2018
Last Update Date: 07/13/2021
Certification Date: 07/13/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3401 CIVIC CENTER BLVD DIVISION OF PEDIATRIC HEMATOLOGY - ONCOLOGY
PHILADELPHIA PA
19104-4319
US

IV. Provider business mailing address

1900 ARCH ST APT 1203
PHILADELPHIA PA
19103-1542
US

V. Phone/Fax

Practice location:
  • Phone: 215-327-3021
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2080P0207X
TaxonomyPediatric Hematology & Oncology Physician
License NumberMT215396
License Number StatePA
# 2
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: