Provider Demographics
NPI:1457323859
Name:GANESAN, SHANTHA (MD)
Entity Type:Individual
Prefix:DR
First Name:SHANTHA
Middle Name:
Last Name:GANESAN
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 1:22303 KINGSBURY AVE
Mailing Address - Street 2:BAYSIDE
Mailing Address - City:OAKLAND GARDENS
Mailing Address - State:NY
Mailing Address - Zip Code:11364-3602
Mailing Address - Country:US
Mailing Address - Phone:718-776-3090
Mailing Address - Fax:718-245-5544
Practice Address - Street 1:451 CLARKSON AVE
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11203-2054
Practice Address - Country:US
Practice Address - Phone:718-245-4409
Practice Address - Fax:718-245-5544
Is Sole Proprietor?:No
Enumeration Date:2006-02-02
Last Update Date:2019-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY214120-1207LP2900X, 207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
No207LP2900XAllopathic & Osteopathic PhysiciansAnesthesiologyPain Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY8L3441Medicare ID - Type Unspecified
NYH78336Medicare UPIN