Provider Demographics
NPI:1053450346
Name:GANJI, PRAMELA R (MD)
Entity Type:Individual
Prefix:DR
First Name:PRAMELA
Middle Name:R
Last Name:GANJI
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 1:1111 MEDICAL CENTER BLVD
Mailing Address - Street 2:STE 304 NORTH
Mailing Address - City:MARRERO
Mailing Address - State:LA
Mailing Address - Zip Code:70072
Mailing Address - Country:US
Mailing Address - Phone:504-737-6860
Mailing Address - Fax:
Practice Address - Street 1:1111 MEDICAL CENTER BLVD
Practice Address - Street 2:STE 304 NORTH
Practice Address - City:MARRERO
Practice Address - State:LA
Practice Address - Zip Code:70072-3151
Practice Address - Country:US
Practice Address - Phone:504-349-6325
Practice Address - Fax:504-349-6327
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-05
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAMD11311R207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1669172Medicaid
LA721479355OtherTAX ID
LAF81384Medicare UPIN
LA5W482Medicare ID - Type UnspecifiedMEDICARE PROVIDER