Provider Demographics
NPI:1093811648
Name:GANAPATHY, SOUMYA (MD)
Entity Type:Individual
Prefix:
First Name:SOUMYA
Middle Name:
Last Name:GANAPATHY
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 1:200 UNICORN PARK DR STE 401
Mailing Address - Street 2:
Mailing Address - City:WOBURN
Mailing Address - State:MA
Mailing Address - Zip Code:01801-3342
Mailing Address - Country:US
Mailing Address - Phone:781-756-6760
Mailing Address - Fax:
Practice Address - Street 1:41 MALL RD
Practice Address - Street 2:
Practice Address - City:BURLINGTON
Practice Address - State:MA
Practice Address - Zip Code:01805-3017
Practice Address - Country:US
Practice Address - Phone:781-744-8000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-14
Last Update Date:2023-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD61187207P00000X
MA2386142083B0002X, 207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No2083B0002XAllopathic & Osteopathic PhysiciansPreventive MedicineObesity Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD404767200Medicaid