Provider Demographics
NPI:1245259365
Name:GANZON, RODOLFO BAUTISTA (MD)
Entity type:Individual
Prefix:
First Name:RODOLFO
Middle Name:BAUTISTA
Last Name:GANZON
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:PO BOX 60447
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28260-0447
Mailing Address - Country:US
Mailing Address - Phone:704-384-9740
Mailing Address - Fax:704-384-9565
Practice Address - Street 1:1500 MATTHEWS TOWNSHIP PKWY
Practice Address - Street 2:
Practice Address - City:MATTHEWS
Practice Address - State:NC
Practice Address - Zip Code:28105-4656
Practice Address - Country:US
Practice Address - Phone:704-384-9740
Practice Address - Fax:704-384-9565
Is Sole Proprietor?:No
Enumeration Date:2006-07-19
Last Update Date:2020-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC200100871207R00000X, 208M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208M00000XAllopathic & Osteopathic PhysiciansHospitalist
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC12994OtherBC BS NC
NC110236348OtherRR MEDICARE
SCN00878Medicaid
NC8912994Medicaid
NC12994OtherBC BS NC