MEDICARE: DR. AMILA VIMARA NISSANKA MD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207Q00000X	Family Medicine Physician	125071582	IL
2	207Q00000X	Family Medicine Physician	036.157093	IL
3	207Q00000X	Family Medicine Physician	74854-20	WI
4	207Q00000X	Family Medicine Physician	63792	AZ
5	207Q00000X	Family Medicine Physician	45836	AL
6	208600000X	Surgery Physician	125071582	IL
7	207Q00000X	Family Medicine Physician	A174462	CA

General Provider Information

NPI Number	:	1073023594
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. AMILA VIMARA NISSANKA MD

Provider Business Mailing Address
First Line	:	20 VIA LOMA
Second Line	:
City	:	LAGUNA NIGUEL
State	:	CA
Zip	:	92677-5148
Country	:	US
Telephone Number	:	949-416-6267
Fax Number	:

Provider Business Practice Location Address
First Line	:	303 BROADWAY ST STE 103
Second Line	:
City	:	LAGUNA BEACH
State	:	CA
Zip	:	92651-1816
Country	:	US
Telephone Number	:	949-665-6000
Fax Number	:	949-670-4967

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	10/10/2017
Last Update Date	:	05/04/2023

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