Provider Demographics
NPI:1033112602
Name:DWIVEDI, GHANSHYAM PRADYUMNA (MD)
Entity Type:Individual
Prefix:DR
First Name:GHANSHYAM
Middle Name:PRADYUMNA
Last Name:DWIVEDI
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1778 METROMEDICAL DR
Mailing Address - Street 2:
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28304-3861
Mailing Address - Country:US
Mailing Address - Phone:910-483-4680
Mailing Address - Fax:910-484-2704
Practice Address - Street 1:1778 METROMEDICAL DR
Practice Address - Street 2:
Practice Address - City:FAYETTEVILLE
Practice Address - State:NC
Practice Address - Zip Code:28304-3861
Practice Address - Country:US
Practice Address - Phone:910-483-4680
Practice Address - Fax:910-484-2704
Is Sole Proprietor?:Yes
Enumeration Date:2005-05-27
Last Update Date:2019-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC33230207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC1033112602OtherNPI
NC8929604Medicaid
NC213198DMedicare ID - Type Unspecified
NCD92797Medicare UPIN