Provider Demographics
NPI:1710970702
Name:GANJHU, LISA (DO)
Entity Type:Individual
Prefix:DR
First Name:LISA
Middle Name:
Last Name:GANJHU
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:355 W 52ND ST
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10019-6239
Mailing Address - Country:US
Mailing Address - Phone:646-754-2100
Mailing Address - Fax:646-754-2148
Practice Address - Street 1:355 W 52ND ST
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10019
Practice Address - Country:US
Practice Address - Phone:646-754-2100
Practice Address - Fax:646-754-2148
Is Sole Proprietor?:No
Enumeration Date:2005-08-25
Last Update Date:2021-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY195085207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01570869Medicaid
NY855211Medicare ID - Type Unspecified
NY01570869Medicaid