Provider Demographics
NPI:1104895580
Name:GANESAN, ANAND K (MD)
Entity type:Individual
Prefix:
First Name:ANAND
Middle Name:K
Last Name:GANESAN
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:PO BOX 513230
Mailing Address - Street 2:UNIV DERMATOLOGY
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90051-3230
Mailing Address - Country:US
Mailing Address - Phone:714-456-8068
Mailing Address - Fax:
Practice Address - Street 1:101 THE CITY DRIVE S
Practice Address - Street 2:UCI MEDICAL CENTER
Practice Address - City:ORANGE
Practice Address - State:CA
Practice Address - Zip Code:92868-3201
Practice Address - Country:US
Practice Address - Phone:714-456-8068
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-03-16
Last Update Date:2008-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXM1101207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAWA85533AMedicare PIN
I36226Medicare UPIN
TXGA08D7743Medicare ID - Type Unspecified