Provider Demographics
NPI:1831114560
Name:GANESAN, DHANA L (MD)
Entity Type:Individual
Prefix:DR
First Name:DHANA
Middle Name:L
Last Name:GANESAN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7357 NORTH AVE
Mailing Address - Street 2:
Mailing Address - City:RIVER FOREST
Mailing Address - State:IL
Mailing Address - Zip Code:60305-1230
Mailing Address - Country:US
Mailing Address - Phone:708-405-6200
Mailing Address - Fax:708-405-6223
Practice Address - Street 1:7357 NORTH AVE
Practice Address - Street 2:
Practice Address - City:RIVER FOREST
Practice Address - State:IL
Practice Address - Zip Code:60305-1230
Practice Address - Country:US
Practice Address - Phone:708-405-6200
Practice Address - Fax:708-405-6223
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-13
Last Update Date:2021-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036094637207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036094637Medicaid
IL036094637Medicaid
G80594Medicare UPIN