Provider Demographics
NPI:1811900657
Name:GANTA, SHYLESH R (MD)
Entity type:Individual
Prefix:
First Name:SHYLESH
Middle Name:R
Last Name:GANTA
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 4083
Mailing Address - Street 2:
Mailing Address - City:MIDLAND
Mailing Address - State:TX
Mailing Address - Zip Code:79704-4083
Mailing Address - Country:US
Mailing Address - Phone:432-683-6558
Mailing Address - Fax:432-682-5104
Practice Address - Street 1:3401 GREENBRIAR STE 100
Practice Address - Street 2:
Practice Address - City:MIDLAND
Practice Address - State:TX
Practice Address - Zip Code:79707-4607
Practice Address - Country:US
Practice Address - Phone:432-683-6558
Practice Address - Fax:432-682-5104
Is Sole Proprietor?:No
Enumeration Date:2006-08-14
Last Update Date:2010-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXK9066207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX132180406Medicaid
TXH12639Medicare UPIN
TX132180406Medicaid
TX8F6462Medicare PIN