Provider Demographics
NPI:1003849407
Name:GANESAN, GEETHA (MD)
Entity Type:Individual
Prefix:
First Name:GEETHA
Middle Name:
Last Name:GANESAN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 735044
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60673-5044
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3289 N MAYFAIR RD
Practice Address - Street 2:
Practice Address - City:WAUWATOSA
Practice Address - State:WI
Practice Address - Zip Code:53222-3203
Practice Address - Country:US
Practice Address - Phone:414-771-7900
Practice Address - Fax:414-607-6336
Is Sole Proprietor?:No
Enumeration Date:2006-07-09
Last Update Date:2023-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI43810207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI34352000Medicaid
WIP00627752OtherRR MEDICARE
H69798Medicare UPIN
WI01994-0325Medicare PIN
WIP00627752OtherRR MEDICARE