Provider Demographics
NPI:1629050638
Name:GANI, AYISHA (MD)
Entity Type:Individual
Prefix:DR
First Name:AYISHA
Middle Name:
Last Name:GANI
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 1:145 RIVERSTONE TERRACE
Mailing Address - Street 2:SUITE 100
Mailing Address - City:CANTON
Mailing Address - State:GA
Mailing Address - Zip Code:30114
Mailing Address - Country:US
Mailing Address - Phone:770-704-9499
Mailing Address - Fax:770-704-9754
Practice Address - Street 1:145 RIVERSTONE TERRACE
Practice Address - Street 2:SUITE 100
Practice Address - City:CANTON
Practice Address - State:GA
Practice Address - Zip Code:30114
Practice Address - Country:US
Practice Address - Phone:770-704-9499
Practice Address - Fax:770-704-9754
Is Sole Proprietor?:Yes
Enumeration Date:2005-11-16
Last Update Date:2012-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA047083207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA00831806AMedicaid
GA00831806AMedicaid
GRP4244Medicare UPIN
G21272Medicare UPIN