Provider Demographics
NPI:1649400581
Name:GHOSE, ABHIMANYU (MD)
Entity Type:Individual
Prefix:DR
First Name:ABHIMANYU
Middle Name:
Last Name:GHOSE
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 1:8283 N HAYDEN RD STE 100
Mailing Address - Street 2:
Mailing Address - City:SCOTTSDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85258-2456
Mailing Address - Country:US
Mailing Address - Phone:810-956-3101
Mailing Address - Fax:480-278-8833
Practice Address - Street 1:3645 S ROME ST STE 209
Practice Address - Street 2:
Practice Address - City:GILBERT
Practice Address - State:AZ
Practice Address - Zip Code:85297-7338
Practice Address - Country:US
Practice Address - Phone:855-485-4673
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-07-24
Last Update Date:2021-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH120199207R00000X
AZ49923207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ123781Medicaid
AZ123781Medicaid