Provider Demographics
NPI:1376537951
Name:GHANTA, AMARANATH (MD,FCCP,D,ABSM)
Entity Type:Individual
Prefix:
First Name:AMARANATH
Middle Name:
Last Name:GHANTA
Suffix:
Gender:M
Credentials:MD,FCCP,D,ABSM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:600 N WASHINGTON AVE
Mailing Address - Street 2:
Mailing Address - City:ODESSA
Mailing Address - State:TX
Mailing Address - Zip Code:79761-4436
Mailing Address - Country:US
Mailing Address - Phone:432-337-5223
Mailing Address - Fax:432-333-5159
Practice Address - Street 1:600 N WASHINGTON AVE
Practice Address - Street 2:
Practice Address - City:ODESSA
Practice Address - State:TX
Practice Address - Zip Code:79761-4436
Practice Address - Country:US
Practice Address - Phone:432-337-5223
Practice Address - Fax:432-333-5159
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-09-09
Last Update Date:2007-07-08
Deactivation Date:2006-03-25
Deactivation Code:
Reactivation Date:2006-04-17
Provider Licenses
StateLicense IDTaxonomies
TXH8654174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX0095CLOtherBLUE CROSS BLUE SHIELD
NMJ3115OtherMEDICAID NEW MEXICO
NMJ3115OtherMEDICAID NEW MEXICO
TX0095CLOtherBLUE CROSS BLUE SHIELD