Provider Demographics
NPI:1891844577
Name:TESFA, GANANA (MD)
Entity Type:Individual
Prefix:DR
First Name:GANANA
Middle Name:
Last Name:TESFA
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 1:2800 E BROAD ST
Mailing Address - Street 2:SUITE 504
Mailing Address - City:MANSFIELD
Mailing Address - State:TX
Mailing Address - Zip Code:76063-6409
Mailing Address - Country:US
Mailing Address - Phone:817-225-0410
Mailing Address - Fax:817-453-9819
Practice Address - Street 1:2800 E BROAD ST
Practice Address - Street 2:SUITE 504
Practice Address - City:MANSFIELD
Practice Address - State:TX
Practice Address - Zip Code:76063
Practice Address - Country:US
Practice Address - Phone:817-225-0410
Practice Address - Fax:817-453-9819
Is Sole Proprietor?:No
Enumeration Date:2007-01-10
Last Update Date:2018-09-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXH76632084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX89M401OtherBLUE CROSS BLUE SHIELD
TX130006869OtherRAILROAD MEDICARE
TX083092901Medicaid
TX119214802Medicaid
TX130006869OtherRAILROAD MEDICARE
TXE66997Medicare UPIN
TX119214802Medicaid