Provider Demographics
NPI:1457459695
Name:GANESHAPPA, RAVI L (MD)
Entity Type:Individual
Prefix:DR
First Name:RAVI
Middle Name:L
Last Name:GANESHAPPA
Suffix:
Gender:M
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:PO BOX 35629
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75235-0629
Mailing Address - Country:US
Mailing Address - Phone:214-424-2200
Mailing Address - Fax:214-231-2159
Practice Address - Street 1:621 CAMDEN STREET
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78215-1639
Practice Address - Country:US
Practice Address - Phone:210-253-3422
Practice Address - Fax:210-227-9833
Is Sole Proprietor?:No
Enumeration Date:2006-09-20
Last Update Date:2017-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXK5534207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX042263602Medicaid
TXP00300726OtherMEDICARE - RAILROAD
TX8M1090OtherBC/BS
TXP00300726OtherMEDICARE - RAILROAD
TX8B7803Medicare ID - Type Unspecified