Basic Information
| Provider Information | |||||||||
| NPI: | 1700851300 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | GUNAWARDENA | ||||||||
| FirstName: | RATNASIRI | ||||||||
| MiddleName: | |||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 850 KEMPSVILLE RD STE 100E | ||||||||
| Address2: | |||||||||
| City: | NORFOLK | ||||||||
| State: | VA | ||||||||
| PostalCode: | 235023920 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7572615744 | ||||||||
| FaxNumber: | 7572610321 | ||||||||
| Practice Location | |||||||||
| Address1: | 850 KEMPSVILLE RD STE 100E | ||||||||
| Address2: | |||||||||
| City: | NORFOLK | ||||||||
| State: | VA | ||||||||
| PostalCode: | 235023920 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7572615744 | ||||||||
| FaxNumber: | 7572610321 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/17/2006 | ||||||||
| LastUpdateDate: | 04/22/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 04/22/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 174400000X | 2003013994 | MO | N | Other Service Providers | Specialist | 207RE0101X | 0101239066 | VA | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Endocrinology, Diabetes & Metabolism |
ID Information
| ID | Type | State | Issuer | Description | 208828608 | 05 | MO | MEDICAID |