Provider Demographics
NPI:1447054184
Name:BANDARA, HERATH MUDIYANSELAGE (MD)
Entity type:Individual
Prefix:
First Name:HERATH
Middle Name:MUDIYANSELAGE
Last Name:BANDARA
Suffix:
Gender:
Credentials:MD
Other - Prefix:
Other - First Name:MANUJI
Other - Middle Name:PRAMODYA
Other - Last Name:BANDARA
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:235 KAOLIN CT
Mailing Address - Street 2:
Mailing Address - City:ALPHARETTA
Mailing Address - State:GA
Mailing Address - Zip Code:30022-7365
Mailing Address - Country:US
Mailing Address - Phone:770-990-6767
Mailing Address - Fax:
Practice Address - Street 1:MERCYHEALTH MULFORD CLINIC
Practice Address - Street 2:5970 CHURCHVIEW DRIVE
Practice Address - City:ROCKFORD
Practice Address - State:IL
Practice Address - Zip Code:61107
Practice Address - Country:US
Practice Address - Phone:815-971-8990
Practice Address - Fax:815-971-9978
Is Sole Proprietor?:No
Enumeration Date:2025-04-02
Last Update Date:2025-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program