Provider Demographics
NPI:1083681134
Name:DEVENDRA, GANESH L (MD)
Entity Type:Individual
Prefix:DR
First Name:GANESH
Middle Name:L
Last Name:DEVENDRA
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 1:22347 N SUMMIT RIDGE CIR
Mailing Address - Street 2:
Mailing Address - City:CHATSWORTH
Mailing Address - State:CA
Mailing Address - Zip Code:91311-2690
Mailing Address - Country:US
Mailing Address - Phone:818-993-8232
Mailing Address - Fax:
Practice Address - Street 1:2925 SYCAMORE DR
Practice Address - Street 2:SUITE 103
Practice Address - City:SIMI VALLEY
Practice Address - State:CA
Practice Address - Zip Code:93065-1208
Practice Address - Country:US
Practice Address - Phone:805-583-0944
Practice Address - Fax:805-526-0417
Is Sole Proprietor?:No
Enumeration Date:2006-03-07
Last Update Date:2011-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA44521174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A445210Medicaid
CA00A445210Medicaid
CAWA44521DMedicare PIN