Provider Demographics
NPI:1255310199
Name:GHANTA, GURU PRASAD (MD)
Entity Type:Individual
Prefix:
First Name:GURU
Middle Name:PRASAD
Last Name:GHANTA
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 1:1015 W FERTITTA BLVD
Mailing Address - Street 2:
Mailing Address - City:LEESVILLE
Mailing Address - State:LA
Mailing Address - Zip Code:71446-4646
Mailing Address - Country:US
Mailing Address - Phone:337-239-4130
Mailing Address - Fax:337-238-4104
Practice Address - Street 1:1015 W FERTITTA BLVD
Practice Address - Street 2:
Practice Address - City:LEESVILLE
Practice Address - State:LA
Practice Address - Zip Code:71446-4646
Practice Address - Country:US
Practice Address - Phone:337-239-4130
Practice Address - Fax:337-238-4104
Is Sole Proprietor?:Yes
Enumeration Date:2006-01-10
Last Update Date:2011-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA05477R174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1313998Medicaid
LA05477ROtherLA. STATE LICENSE
LA720946706OtherTAX ID #
LA720946706OtherTAX ID #
LA51051Medicare ID - Type UnspecifiedMEDICARE PROVIDER #