Provider Demographics
NPI:1063413128
Name:GANTI, KRISHNA M (MD)
Entity type:Individual
Prefix:DR
First Name:KRISHNA
Middle Name:M
Last Name:GANTI
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 1:11373 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
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-08-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL048997174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL02407OtherBLUE CROSS
FL00238OtherUNIVERSAL HMO
FL09499OtherWELLCARE HMO
FL09499OtherWELLCARE HMO
FLD50499Medicare UPIN