Provider Demographics
NPI:1982688016
Name:GANESHAN, VATHSALA (MD)
Entity Type:Individual
Prefix:
First Name:VATHSALA
Middle Name:
Last Name:GANESHAN
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 1:8170 33RD AVE S
Mailing Address - Street 2:MS21110Q
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55425-4516
Mailing Address - Country:US
Mailing Address - Phone:952-883-5375
Mailing Address - Fax:651-293-8106
Practice Address - Street 1:205 S WABASHA ST
Practice Address - Street 2:MAIL STOP 31300A - HEALTHPARTNERS ST. PAUL CLINIC
Practice Address - City:ST. PAUL
Practice Address - State:MN
Practice Address - Zip Code:55107-1805
Practice Address - Country:US
Practice Address - Phone:651-293-8100
Practice Address - Fax:651-293-8106
Is Sole Proprietor?:No
Enumeration Date:2005-12-02
Last Update Date:2012-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN42408208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
MNH16176Medicare UPIN
MN370002838Medicare ID - Type Unspecified