Basic Information
| Provider Information | |||||||||
| NPI: | 1255328266 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | GANJI | ||||||||
| FirstName: | JYOTI | ||||||||
| MiddleName: | B | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 130 | ||||||||
| Address2: | |||||||||
| City: | SAN FIDEL | ||||||||
| State: | NM | ||||||||
| PostalCode: | 870490130 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5055525300 | ||||||||
| FaxNumber: | 5055525490 | ||||||||
| Practice Location | |||||||||
| Address1: | 80 B VETERANS BLVD | ||||||||
| Address2: | |||||||||
| City: | ACOMA | ||||||||
| State: | NM | ||||||||
| PostalCode: | 87034 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5055525300 | ||||||||
| FaxNumber: | 5055525490 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/04/2005 | ||||||||
| LastUpdateDate: | 11/23/2016 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208600000X | 06964R | LA | Y | Allopathic & Osteopathic Physicians | Surgery | 208600000X | 22011 | KS | N | Allopathic & Osteopathic Physicians | Surgery | 208600000X | 13972 | AZ | N | Allopathic & Osteopathic Physicians | Surgery |
ID Information
| ID | Type | State | Issuer | Description | 1979627 | 05 | LA | MEDICAID | H3451 | 05 | NM | MEDICAID |