Provider Demographics
NPI:1518958057
Name:GANDHAVADI, RANJINI B (MD)
Entity Type:Individual
Prefix:
First Name:RANJINI
Middle Name:B
Last Name:GANDHAVADI
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Other - Credentials:
Mailing Address - Street 1:4425 N PORT WASHINGTON RD
Mailing Address - Street 2:ATTN: CSMCP CLINIC CREDENTIALING
Mailing Address - City:GLENDALE
Mailing Address - State:WI
Mailing Address - Zip Code:53212-1082
Mailing Address - Country:US
Mailing Address - Phone:414-291-1556
Mailing Address - Fax:414-291-1557
Practice Address - Street 1:2350 N LAKE DR
Practice Address - Street 2:SUITE G01
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53211-4528
Practice Address - Country:US
Practice Address - Phone:414-291-1556
Practice Address - Fax:414-291-1557
Is Sole Proprietor?:No
Enumeration Date:2005-11-03
Last Update Date:2012-06-11
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
WI22791-0202085R0001X, 2085R0203X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0001XAllopathic & Osteopathic PhysiciansRadiologyRadiation Oncology
No2085R0203XAllopathic & Osteopathic PhysiciansRadiologyTherapeutic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI920005883OtherRAILROAD MEDICARE
WI30456100Medicaid
WI30456100Medicaid
WI30456100Medicaid
WI$$$$$$$$$008OtherBC/BS
B84867Medicare UPIN
WI000202104Medicare ID - Type Unspecified