Provider Demographics
NPI:1952547507
Name:KRISHNA M GANTI MD PA
Entity Type:Organization
Organization Name:KRISHNA M GANTI MD PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:INITIAL OFFICER AND/OR DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:KRISHNA
Authorized Official - Middle Name:M
Authorized Official - Last Name:GANTI
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:352-596-6158
Mailing Address - Street 1:11373 CORTEZ BLVD
Mailing Address - Street 2:SUITE 203
Mailing Address - City:BROOKSVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:34613-5414
Mailing Address - Country:US
Mailing Address - Phone:352-596-6158
Mailing Address - Fax:352-596-6186
Practice Address - Street 1:11373 CORTEZ BLVD
Practice Address - Street 2:SUITE 203
Practice Address - City:BROOKSVILLE
Practice Address - State:FL
Practice Address - Zip Code:34613-5414
Practice Address - Country:US
Practice Address - Phone:352-596-6158
Practice Address - Fax:352-596-6186
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-01-05
Last Update Date:2009-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME48997207Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL1952547507OtherMEDICARE GROUP NPI
FL40001752OtherRAILROAD MEDICARE
FL57664600Medicaid
FL09499OtherWELLCARE
FL02407OtherBLUE CROSS FLORIDA
FL1063413128OtherMEDICARE INDIVIDUAL NPI
FL02407YOtherMEDICARE INDIVIDUAL PTAN
FLBJ359OtherMEDICARE GROUP PTAN
FL40001752OtherRAILROAD MEDICARE