Provider Demographics
NPI:1508885955
Name:GANJI, SRINIVAS S (MD)
Entity Type:Individual
Prefix:
First Name:SRINIVAS
Middle Name:S
Last Name:GANJI
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 1:209 HIGHLAND PARK PLZ
Mailing Address - Street 2:
Mailing Address - City:COVINGTON
Mailing Address - State:LA
Mailing Address - Zip Code:70433-7130
Mailing Address - Country:US
Mailing Address - Phone:985-892-6291
Mailing Address - Fax:985-892-8077
Practice Address - Street 1:209 HIGHLAND PARK PLZ
Practice Address - Street 2:
Practice Address - City:COVINGTON
Practice Address - State:LA
Practice Address - Zip Code:70433-7130
Practice Address - Country:US
Practice Address - Phone:985-892-6291
Practice Address - Fax:985-892-8077
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-18
Last Update Date:2012-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA05634R2084N0400X, 2084S0012X, 2084N0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
No2084S0012XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologySleep Medicine
No2084N0600XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyClinical Neurophysiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1324353Medicaid
LA51089Medicare ID - Type Unspecified
LA1324353Medicaid
LAB62799Medicare UPIN