Provider Demographics
NPI:1861656548
Name:GHANTA, MAHENDRA (MD)
Entity Type:Individual
Prefix:DR
First Name:MAHENDRA
Middle Name:
Last Name:GHANTA
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 1:5107 MEDICAL DR
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78229-4801
Mailing Address - Country:US
Mailing Address - Phone:210-614-8612
Mailing Address - Fax:
Practice Address - Street 1:5107 MEDICAL DR
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78229-4801
Practice Address - Country:US
Practice Address - Phone:210-614-8612
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-07-11
Last Update Date:2024-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT49811207R00000X
390200000X
TXP9856207RE0101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RE0101XAllopathic & Osteopathic PhysiciansInternal MedicineEndocrinology, Diabetes & Metabolism
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program