Provider Demographics
NPI:1457332538
Name:GANESAN, GEORGE S (MD)
Entity Type:Individual
Prefix:
First Name:GEORGE
Middle Name:S
Last Name:GANESAN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:GANESAN
Other - Middle Name:S
Other - Last Name:GNANASEKARAM
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:6670 S. TANAYA WAY
Mailing Address - Street 2:SUITE 180
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89113
Mailing Address - Country:US
Mailing Address - Phone:702-369-4999
Mailing Address - Fax:702-369-2993
Practice Address - Street 1:3201 S MARYLAND PKWY
Practice Address - Street 2:SUITE 406
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89109-2441
Practice Address - Country:US
Practice Address - Phone:702-369-4999
Practice Address - Fax:702-369-2993
Is Sole Proprietor?:Yes
Enumeration Date:2005-11-07
Last Update Date:2014-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV6402174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV20-19187Medicaid
NV35202Medicare PIN
NVB06274Medicare UPIN