Provider Demographics
NPI:1598794570
Name:GANESA, PRASANTHI (MD)
Entity Type:Individual
Prefix:DR
First Name:PRASANTHI
Middle Name:
Last Name:GANESA
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:800 W MAGNOLIA AVE
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76104-4611
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:800 W MAGNOLIA AVE
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76104-4611
Practice Address - Country:US
Practice Address - Phone:817-759-7000
Practice Address - Fax:817-759-7027
Is Sole Proprietor?:No
Enumeration Date:2006-07-01
Last Update Date:2023-07-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXM3406207RH0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RH0003XAllopathic & Osteopathic PhysiciansInternal MedicineHematology & Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX1944407-02Medicaid
TX1944407-01Medicaid
TX8K4539Medicare PIN
TX8K4538Medicare PIN
TXI61649Medicare UPIN
TXTXB102986Medicare PIN