Provider Demographics
NPI:1760547392
Name:GANTA, SANYASI R (MD,)
Entity Type:Individual
Prefix:DR
First Name:SANYASI
Middle Name:R
Last Name:GANTA
Suffix:
Gender:M
Credentials:MD,
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:850 E LATHAM AVE
Mailing Address - Street 2:STE 201
Mailing Address - City:HEMET
Mailing Address - State:CA
Mailing Address - Zip Code:92543-4391
Mailing Address - Country:US
Mailing Address - Phone:951-925-6657
Mailing Address - Fax:951-929-0907
Practice Address - Street 1:850 E LATHAM AVE
Practice Address - Street 2:STE 201
Practice Address - City:HEMET
Practice Address - State:CA
Practice Address - Zip Code:92543-4391
Practice Address - Country:US
Practice Address - Phone:951-925-6657
Practice Address - Fax:951-929-0907
Is Sole Proprietor?:No
Enumeration Date:2006-12-26
Last Update Date:2013-05-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA70985207Q00000X, 207QG0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No207QG0300XAllopathic & Osteopathic PhysiciansFamily MedicineGeriatric Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A709851Medicare PIN