Provider Demographics
NPI:1376645820
Name:GANJI, UZVALTHA (MD)
Entity Type:Individual
Prefix:
First Name:UZVALTHA
Middle Name:
Last Name:GANJI
Suffix:
Gender:F
Credentials:MD
Other - Prefix:DR
Other - First Name:LATHA
Other - Middle Name:
Other - Last Name:GANJI
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:5220 LARK LN
Mailing Address - Street 2:
Mailing Address - City:ALEXANDRIA
Mailing Address - State:LA
Mailing Address - Zip Code:71303-2435
Mailing Address - Country:US
Mailing Address - Phone:318-442-0970
Mailing Address - Fax:
Practice Address - Street 1:2495 SHREVEPORT HWY # HWY.71NORTH
Practice Address - Street 2:MEDICAL CERVISE 111
Practice Address - City:PINEVILLE
Practice Address - State:LA
Practice Address - Zip Code:71360-4044
Practice Address - Country:US
Practice Address - Phone:318-473-0010
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA14907R207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1578215Medicaid
LA4F017Medicare ID - Type Unspecified
LA1578215Medicaid