Provider Demographics
NPI:1407098767
Name:GANSKE, INGRID (MD)
Entity Type:Individual
Prefix:
First Name:INGRID
Middle Name:
Last Name:GANSKE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:300 LONGWOOD AVE
Mailing Address - Street 2:ENDERS 123
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02115-5724
Mailing Address - Country:US
Mailing Address - Phone:617-355-1463
Mailing Address - Fax:
Practice Address - Street 1:330 LONGWOOD AVE
Practice Address - Street 2:
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02115-5746
Practice Address - Country:US
Practice Address - Phone:617-355-1463
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-04-01
Last Update Date:2016-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA2624882086S0122X
MEMD210762086S0122X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086S0122XAllopathic & Osteopathic PhysiciansSurgeryPlastic and Reconstructive Surgery