Provider Demographics
NPI:1235322165
Name:GANTI, KENNEDY U (MD)
Entity Type:Individual
Prefix:DR
First Name:KENNEDY
Middle Name:U
Last Name:GANTI
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:1 FEDERAL ST # 200
Mailing Address - Street 2:
Mailing Address - City:CAMDEN
Mailing Address - State:NJ
Mailing Address - Zip Code:08103-1088
Mailing Address - Country:US
Mailing Address - Phone:856-356-4924
Mailing Address - Fax:
Practice Address - Street 1:651 JOHN F KENNEDY WAY
Practice Address - Street 2:
Practice Address - City:WILLINGBORO
Practice Address - State:NJ
Practice Address - Zip Code:08046-1262
Practice Address - Country:US
Practice Address - Phone:609-835-2838
Practice Address - Fax:609-589-3841
Is Sole Proprietor?:No
Enumeration Date:2007-08-23
Last Update Date:2024-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA081524002083C0008X, 207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No2083C0008XAllopathic & Osteopathic PhysiciansPreventive MedicineClinical Informatics
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ0146471Medicaid
NJ116894YBAWMedicare PIN
NJ0146471Medicaid