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Annesley T Devasgunawardhane, MD

Individual provider Active NPI Family Medicine Physician · Clifton, IL

NPI 1235148693 · NPPES record last updated Jul 8, 2007

Key facts

NPI
1235148693
Entity type
Individual (NPI type 1)
Primary specialty
Family Medicine Physician 207Q00000X
License
036-054736 (IL)
Practice address
102 Commerce Dr
Clifton, IL 60927-9501
Phone
(815) 694-2381
Fax
(815) 694-2256
NPI assigned
Aug 5, 2006
Sex
Male
Sole proprietor
No

Organizations & group practices 1

Organizations this provider is connected to: Medicare benefit reassignments (the organization bills Medicare for this provider’s services), Care Compare group memberships and National Provider Directory roles.

Medicare participation

Medicare fee-for-service enrollment
Not listed in the public Medicare enrollment file

National Provider Directory

Medicare enrollment (NPD)
Yes
Credentials
Doctor of Medicine

State licenses

LicenseStateTypeSpecialty
036-054736ILMDFamily Medicine Physician

Practice roles

OrganizationSpecialtyStatusNew patients
Gibson Community Hospital Association Past Accepting new patients

Specialties & licenses

Specialty (taxonomy)CodeLicenseStatePrimary
Family Medicine Physician 207Q00000X 036-054736 IL Yes

Addresses

Primary practice location

102 Commerce Dr
Clifton, IL 60927-9501

Mailing address

102 Commerce Dr
Clifton, IL 60927-9501
Phone (815) 694-2381

Other identifiers

IdentifierTypeStateIssuer
036054736MedicaidIL

Other names

  • Ted Devas Professional name

Other providers in Clifton, IL

All providers in Clifton, IL · Family Medicine Physician in Illinois

Sources for this page

Verify at the official NPI Registry.