Provider Demographics
NPI:1982614632
Name:GHANTA, KALYAN (MD)
Entity Type:Individual
Prefix:
First Name:KALYAN
Middle Name:
Last Name:GHANTA
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 1:100 HITCHCOCK WAY
Mailing Address - Street 2:DEPARTMENT OF CARDIOLOGY
Mailing Address - City:MANCHESTER
Mailing Address - State:NH
Mailing Address - Zip Code:03104-4125
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:100 HITCHCOCK WAY
Practice Address - Street 2:DEPARTMENT OF CARDIOLOGY
Practice Address - City:MANCHESTER
Practice Address - State:NH
Practice Address - Zip Code:03104-4125
Practice Address - Country:US
Practice Address - Phone:603-629-8288
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-08
Last Update Date:2016-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NH15024207R00000X, 207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN084910000Medicaid
NH3091028Medicaid
WI34888300Medicaid
VT1018569Medicaid
VT1018569Medicaid