Provider Demographics
NPI:1841236395
Name:GANTA, PRAMOD REDDY (MD)
Entity Type:Individual
Prefix:DR
First Name:PRAMOD
Middle Name:REDDY
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 1:2508 N MAIN ST STE G
Mailing Address - Street 2:
Mailing Address - City:ANDERSON
Mailing Address - State:SC
Mailing Address - Zip Code:29621-3266
Mailing Address - Country:US
Mailing Address - Phone:864-540-8430
Mailing Address - Fax:866-421-1896
Practice Address - Street 1:2508 N MAIN ST STE G
Practice Address - Street 2:
Practice Address - City:ANDERSON
Practice Address - State:SC
Practice Address - Zip Code:29621
Practice Address - Country:US
Practice Address - Phone:864-540-8430
Practice Address - Fax:866-421-1896
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-22
Last Update Date:2018-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS19517174400000X, 208M00000X
SC35066207RH0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RH0003XAllopathic & Osteopathic PhysiciansInternal MedicineHematology & Oncology
No174400000XOther Service ProvidersSpecialist
No208M00000XAllopathic & Osteopathic PhysiciansHospitalist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS7460782OtherAETNA
LA1124249Medicaid
MSP00417392OtherRAILROAD MEDICARE
MS07502764Medicaid
MS07502764Medicaid