Provider Demographics
NPI:1508187162
Name:GANPOT, SALLYANN JESSIE (MD)
Entity Type:Individual
Prefix:DR
First Name:SALLYANN
Middle Name:JESSIE
Last Name:GANPOT
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 1:840 N OAK AVE
Mailing Address - Street 2:
Mailing Address - City:RULEVILLE
Mailing Address - State:MS
Mailing Address - Zip Code:38771-3227
Mailing Address - Country:US
Mailing Address - Phone:662-756-1788
Mailing Address - Fax:662-756-1694
Practice Address - Street 1:840 N OAK AVE
Practice Address - Street 2:
Practice Address - City:RULEVILLE
Practice Address - State:MS
Practice Address - Zip Code:38771-3227
Practice Address - Country:US
Practice Address - Phone:662-756-1788
Practice Address - Fax:662-756-1694
Is Sole Proprietor?:No
Enumeration Date:2010-06-17
Last Update Date:2016-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS21136208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics