Provider Demographics
NPI:1508204009
Name:GANESAN, THIYAGU (MD)
Entity Type:Individual
Prefix:DR
First Name:THIYAGU
Middle Name:
Last Name:GANESAN
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 1:5730 PACKARD AVE
Mailing Address - Street 2:SUITE 500
Mailing Address - City:MARYSVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:95901-7118
Mailing Address - Country:US
Mailing Address - Phone:530-749-3242
Mailing Address - Fax:530-749-3248
Practice Address - Street 1:5730 PACKARD AVENUE
Practice Address - Street 2:SUITE NO: 500
Practice Address - City:MARYSVILLE
Practice Address - State:CA
Practice Address - Zip Code:95993
Practice Address - Country:US
Practice Address - Phone:530-749-3242
Practice Address - Fax:530-749-3248
Is Sole Proprietor?:Yes
Enumeration Date:2013-06-06
Last Update Date:2016-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA140735208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics