Provider Demographics
NPI:1558304261
Name:GANJAM, RAGHU D (MD)
Entity Type:Individual
Prefix:DR
First Name:RAGHU
Middle Name:D
Last Name:GANJAM
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 1:1507 S HIAWASSEE RD
Mailing Address - Street 2:SUITE 107
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32835-5718
Mailing Address - Country:US
Mailing Address - Phone:407-445-9545
Mailing Address - Fax:407-445-9365
Practice Address - Street 1:1507 S HIAWASSEE RD
Practice Address - Street 2:SUITE 107
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32835-5718
Practice Address - Country:US
Practice Address - Phone:407-445-9545
Practice Address - Fax:407-445-9365
Is Sole Proprietor?:No
Enumeration Date:2006-06-13
Last Update Date:2022-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME87933207R00000X, 207RA0401X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No207RA0401XAllopathic & Osteopathic PhysiciansInternal MedicineAddiction Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL268463200Medicaid
FL268463200Medicaid
FL81210ZMedicare ID - Type Unspecified