Provider Demographics
NPI:1467987677
Name:GANESAN, GOUTHAM
Entity Type:Individual
Prefix:
First Name:GOUTHAM
Middle Name:
Last Name:GANESAN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:101 MANNING DR
Mailing Address - Street 2:CAMPUS BOX 7160
Mailing Address - City:CHAPEL HILL
Mailing Address - State:NC
Mailing Address - Zip Code:27514-4220
Mailing Address - Country:US
Mailing Address - Phone:480-370-8598
Mailing Address - Fax:
Practice Address - Street 1:101 MANNING DR
Practice Address - Street 2:CAMPUS BOX 7160
Practice Address - City:CHAPEL HILL
Practice Address - State:NC
Practice Address - Zip Code:27514-4220
Practice Address - Country:US
Practice Address - Phone:480-370-8598
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-04-25
Last Update Date:2022-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC226934390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program