Provider Demographics
NPI:1629289517
Name:GANESH, VISHAL ATAISH (MD)
Entity Type:Individual
Prefix:
First Name:VISHAL
Middle Name:ATAISH
Last Name:GANESH
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:P.O. BOX 29870
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85038
Mailing Address - Country:US
Mailing Address - Phone:602-772-3805
Mailing Address - Fax:602-772-3801
Practice Address - Street 1:10450 W MCDOWELL RD
Practice Address - Street 2:STE 102
Practice Address - City:AVONDALE
Practice Address - State:AZ
Practice Address - Zip Code:85392-4901
Practice Address - Country:US
Practice Address - Phone:623-846-7614
Practice Address - Fax:623-846-0993
Is Sole Proprietor?:No
Enumeration Date:2007-05-24
Last Update Date:2011-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ44706174400000X, 207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ4Z0125OtherHEALTHNET
AZ620765Medicaid
AZ620765Medicaid
AZP00959240Medicare PIN