Provider Demographics
NPI:1689746299
Name:PERERA, GANESHA B (MD)
Entity Type:Individual
Prefix:DR
First Name:GANESHA
Middle Name:B
Last Name:PERERA
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:PO BOX 1524
Mailing Address - Street 2:
Mailing Address - City:AUGUSTA
Mailing Address - State:GA
Mailing Address - Zip Code:30903-1524
Mailing Address - Country:US
Mailing Address - Phone:706-774-7263
Mailing Address - Fax:706-774-7230
Practice Address - Street 1:1350 WALTON WAY
Practice Address - Street 2:
Practice Address - City:AUGUSTA
Practice Address - State:GA
Practice Address - Zip Code:30901-2612
Practice Address - Country:US
Practice Address - Phone:706-774-7022
Practice Address - Fax:706-774-7023
Is Sole Proprietor?:No
Enumeration Date:2006-11-15
Last Update Date:2022-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC314632086S0129X
GA0609642086S0129X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086S0129XAllopathic & Osteopathic PhysiciansSurgeryVascular Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC029OtherTRICARE
SC067OtherBLUE CHOICE
SCAA46098552OtherMEDICARE PTAN
SC067OtherBCBS
SCG60964Medicaid
SC224310OtherMEDCOST