Basic Information
| Provider Information | |||||||||
| NPI: | 1558363671 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | GANGADHARAN | ||||||||
| FirstName: | MEERA | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3533 S ALAMEDA ST | ||||||||
| Address2: | |||||||||
| City: | CORPUS CHRISTI | ||||||||
| State: | TX | ||||||||
| PostalCode: | 784111721 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3616945445 | ||||||||
| FaxNumber: | 3616945449 | ||||||||
| Practice Location | |||||||||
| Address1: | 3533 S ALAMEDA ST | ||||||||
| Address2: | |||||||||
| City: | CORPUS CHRISTI | ||||||||
| State: | TX | ||||||||
| PostalCode: | 784111721 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3616945445 | ||||||||
| FaxNumber: | 3616945449 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/01/2005 | ||||||||
| LastUpdateDate: | 05/27/2010 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | L0190 | TX | N | Allopathic & Osteopathic Physicians | Pediatrics | 207L00000X | L0190 | TX | Y | Allopathic & Osteopathic Physicians | Anesthesiology |
ID Information
| ID | Type | State | Issuer | Description | 140939301 | 05 | TX | MEDICAID |