Basic Information
| Provider Information | |||||||||
| NPI: | 1295796969 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | DISSANAYAKE | ||||||||
| FirstName: | IMARA | ||||||||
| MiddleName: | R | ||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 101 EAST OLNEY AVE | ||||||||
| Address2: | STE 400 | ||||||||
| City: | PHILADELPHIA | ||||||||
| State: | PA | ||||||||
| PostalCode: | 19120 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2154567000 | ||||||||
| FaxNumber: | 2152542599 | ||||||||
| Practice Location | |||||||||
| Address1: | 5501 OLD YORK RD | ||||||||
| Address2: | |||||||||
| City: | PHILA | ||||||||
| State: | PA | ||||||||
| PostalCode: | 19144 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2154566970 | ||||||||
| FaxNumber: | 2154567154 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/31/2006 | ||||||||
| LastUpdateDate: | 12/09/2011 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RN0300X | MD072898L | PA | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Nephrology |
ID Information
| ID | Type | State | Issuer | Description | 001866922 | 05 | PA | MEDICAID |