Provider Demographics
NPI:1881889657
Name:GANGADHARAN, VENKATARAMANAN (MBBS)
Entity type:Individual
Prefix:DR
First Name:VENKATARAMANAN
Middle Name:
Last Name:GANGADHARAN
Suffix:
Gender:M
Credentials:MBBS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:19636 N 27TH AVE STE 401
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85027-4021
Mailing Address - Country:US
Mailing Address - Phone:602-861-1168
Mailing Address - Fax:480-882-5891
Practice Address - Street 1:19636 N 27TH AVE STE 401
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85027-4021
Practice Address - Country:US
Practice Address - Phone:602-861-1168
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-09-13
Last Update Date:2023-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME120626207RC0000X
VA390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA1881889657Medicaid
KY7100161250Medicaid
TNP01081165OtherRAILROAD MEDICARE
TN1523202Medicaid
TN103I116831Medicare PIN