Basic Information
| Provider Information | |||||||||
| NPI: | 1215923701 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GANGASANI | ||||||||
| FirstName: | SREENI | ||||||||
| MiddleName: | R. | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 755 WALTHER RD | ||||||||
| Address2: | |||||||||
| City: | LAWRENCEVILLE | ||||||||
| State: | GA | ||||||||
| PostalCode: | 300468725 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7709620399 | ||||||||
| FaxNumber: | 7709950533 | ||||||||
| Practice Location | |||||||||
| Address1: | 755 WALTHER RD | ||||||||
| Address2: | |||||||||
| City: | LAWRENCEVILLE | ||||||||
| State: | GA | ||||||||
| PostalCode: | 300468725 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7709620399 | ||||||||
| FaxNumber: | 7709950533 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/21/2005 | ||||||||
| LastUpdateDate: | 07/16/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 07/16/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RC0000X | 48777 | GA | N | Allopathic & Osteopathic Physicians | Internal Medicine | Cardiovascular Disease | 207UN0901X | 48777 | GA | N | Allopathic & Osteopathic Physicians | Nuclear Medicine | Nuclear Cardiology | 207RA0001X | 48777 | GA | Y |
ID Information
| ID | Type | State | Issuer | Description | 00866412E | 05 | GA | MEDICAID |