Provider Demographics
NPI:1891794459
Name:DALSANIA, KETAN CHHAGAN (DPM)
Entity Type:Individual
Prefix:
First Name:KETAN
Middle Name:CHHAGAN
Last Name:DALSANIA
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:705 17TH ST
Mailing Address - Street 2:STE 200
Mailing Address - City:COLUMBUS
Mailing Address - State:GA
Mailing Address - Zip Code:31901-3507
Mailing Address - Country:US
Mailing Address - Phone:706-322-7884
Mailing Address - Fax:706-660-2142
Practice Address - Street 1:705 17TH ST
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:GA
Practice Address - Zip Code:31901-3500
Practice Address - Country:US
Practice Address - Phone:706-322-7884
Practice Address - Fax:706-322-7884
Is Sole Proprietor?:No
Enumeration Date:2005-07-17
Last Update Date:2019-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL287213ES0103X
GAPOD001033213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA633189238Medicaid
GA633189238BMedicaid
GA202I480270Medicare PIN