Provider Demographics
NPI:1174834865
Name:GANACIAS, KAREN GAYLE (MD)
Entity Type:Individual
Prefix:
First Name:KAREN
Middle Name:GAYLE
Last Name:GANACIAS
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 1:1600 GRANBY ST APT 456
Mailing Address - Street 2:
Mailing Address - City:NORFOLK
Mailing Address - State:VA
Mailing Address - Zip Code:23510-2661
Mailing Address - Country:US
Mailing Address - Phone:913-683-5707
Mailing Address - Fax:
Practice Address - Street 1:692A RITCHIE HWY
Practice Address - Street 2:
Practice Address - City:SEVERNA PARK
Practice Address - State:MD
Practice Address - Zip Code:21146-3971
Practice Address - Country:US
Practice Address - Phone:410-721-2273
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-06-28
Last Update Date:2018-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD86067208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
MDPENDINGMedicaid