Provider Demographics
NPI:1841211661
Name:GANTI, SHYAMALA (MD)
Entity Type:Individual
Prefix:
First Name:SHYAMALA
Middle Name:
Last Name:GANTI
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 1:1756 W ANGELICA LOOP
Mailing Address - Street 2:LECANTO
Mailing Address - City:LECANTO
Mailing Address - State:FL
Mailing Address - Zip Code:34461-6400
Mailing Address - Country:US
Mailing Address - Phone:937-271-1832
Mailing Address - Fax:
Practice Address - Street 1:2804 W MARC KNIGHTON CT
Practice Address - Street 2:LECANTO
Practice Address - City:LECANTO
Practice Address - State:FL
Practice Address - Zip Code:34461-6300
Practice Address - Country:US
Practice Address - Phone:937-271-1832
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35076166207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine