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General NPI Number Information
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NPI Number | 1447054184
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Entity Type | Individual
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Provider Name | HERATH MUDIYANSELAGE BANDARA MD
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Gender | Female
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Dates
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Enumeration Date | 04/02/2025
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Last Update Date | 04/02/2025
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Provider Practice Location Address
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Address Line | MERCYHEALTH MULFORD CLINIC 5970 CHURCHVIEW DRIVE
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City | ROCKFORD
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State | IL
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Zip | 61107
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Country | US
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Telephone | 815-971-8990
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Fax | 815-971-9978
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Provider Business Mailing Address
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Address Line | 235 KAOLIN CT
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City | ALPHARETTA
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State | GA
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Zip | 30022-7365
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Country | US
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Telephone | 770-990-6767
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 390200000X
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Taxonomy Name | Student in an Organized Health Care Education/Training Program
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License Number |
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License Number State |
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