Provider Demographics
NPI:1538104096
Name:GANZ, KEYVAN (DPM)
Entity Type:Individual
Prefix:DR
First Name:KEYVAN
Middle Name:
Last Name:GANZ
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:DR
Other - First Name:KEYVAN
Other - Middle Name:
Other - Last Name:GANJIANPOUR
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DPM
Mailing Address - Street 1:2295 PARKLAKE DR NE STE 150
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30345-2825
Mailing Address - Country:US
Mailing Address - Phone:770-746-4101
Mailing Address - Fax:
Practice Address - Street 1:2295 PARKLAKE DR NE STE 150
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30345-2825
Practice Address - Country:US
Practice Address - Phone:770-746-4101
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-18
Last Update Date:2024-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1779213E00000X
FL901365213E00000X
AZ0167213E00000X
CAE5728213ES0000X
VA0103301393213ES0103X
GAPOD305010213ES0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0000XPodiatric Medicine & Surgery Service ProvidersPodiatristSports Medicine
No213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
No213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXV08735Medicare UPIN
8G4704Medicare ID - Type Unspecified