Basic Information
| Provider Information | |||||||||
| NPI: | 1972168938 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | SONNADARA | ||||||||
| FirstName: | ISURUNI | ||||||||
| MiddleName: | GAYANATHIKA | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 6675 WESTWOOD BLVD STE 475 | ||||||||
| Address2: | |||||||||
| City: | ORLANDO | ||||||||
| State: | FL | ||||||||
| PostalCode: | 328216027 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4078450330 | ||||||||
| FaxNumber: | 8889721752 | ||||||||
| Practice Location | |||||||||
| Address1: | 4725 US HIGHWAY 98 S STE 102 | ||||||||
| Address2: | |||||||||
| City: | LAKELAND | ||||||||
| State: | FL | ||||||||
| PostalCode: | 338124334 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8636469663 | ||||||||
| FaxNumber: | 8636469664 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/06/2019 | ||||||||
| LastUpdateDate: | 06/14/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 06/14/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 2019009322 | MO | N | Allopathic & Osteopathic Physicians | Family Medicine | 208D00000X | ACN1431 | FL | Y | Allopathic & Osteopathic Physicians | General Practice |
No ID Information.