Provider Demographics
NPI:1821060807
Name:GANTA, SASHIDHAR V (MD)
Entity Type:Individual
Prefix:DR
First Name:SASHIDHAR
Middle Name:V
Last Name:GANTA
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 200185
Mailing Address - Street 2:
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78720-0185
Mailing Address - Country:US
Mailing Address - Phone:512-244-6452
Mailing Address - Fax:512-244-6582
Practice Address - Street 1:11851 JOLLYVILLE RD STE 4
Practice Address - Street 2:
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78759-2350
Practice Address - Country:US
Practice Address - Phone:512-952-0341
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-02-03
Last Update Date:2023-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXM2325208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX178759001Medicaid
TX178758201Medicaid
TX00W087Medicare ID - Type UnspecifiedGROUP #