Provider Demographics
NPI:1043696305
Name:SIVAGURU, GANESAN (OD)
Entity Type:Individual
Prefix:DR
First Name:GANESAN
Middle Name:
Last Name:SIVAGURU
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:201 SHANNON CT
Mailing Address - Street 2:
Mailing Address - City:SALISBURY
Mailing Address - State:MD
Mailing Address - Zip Code:21804-1974
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3556A S JEFFERSON ST
Practice Address - Street 2:
Practice Address - City:BAILEYS CROSSROADS
Practice Address - State:VA
Practice Address - Zip Code:22041-3119
Practice Address - Country:US
Practice Address - Phone:703-379-1100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-08-09
Last Update Date:2017-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0618002463152W00000X, 152WC0802X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
No152WC0802XEye and Vision Services ProvidersOptometristCorneal and Contact Management