Provider Demographics
NPI:1356498323
Name:GANESH, SELVA (MD)
Entity Type:Individual
Prefix:DR
First Name:SELVA
Middle Name:
Last Name:GANESH
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 1:211 E BOYNTON BEACH BLVD
Mailing Address - Street 2:
Mailing Address - City:BOYNTON BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33435-3839
Mailing Address - Country:US
Mailing Address - Phone:561-732-3200
Mailing Address - Fax:561-732-6849
Practice Address - Street 1:211 E BOYNTON BEACH BLVD
Practice Address - Street 2:
Practice Address - City:BOYNTON BEACH
Practice Address - State:FL
Practice Address - Zip Code:33435-3839
Practice Address - Country:US
Practice Address - Phone:561-732-3200
Practice Address - Fax:561-732-6849
Is Sole Proprietor?:No
Enumeration Date:2007-01-04
Last Update Date:2011-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME0025890174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL055845100Medicaid
FL50723ZMedicare UPIN
FL055845100Medicaid