Provider Demographics
NPI:1154515625
Name:GANATRA, NAUTAM B (MD)
Entity type:Individual
Prefix:
First Name:NAUTAM
Middle Name:B
Last Name:GANATRA
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 1:909 FROSTWOOD DR STE 1.100
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77024-2301
Mailing Address - Country:US
Mailing Address - Phone:504-412-3700
Mailing Address - Fax:
Practice Address - Street 1:11800 ASTORIA BLVD
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77089-6041
Practice Address - Country:US
Practice Address - Phone:281-929-6180
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-08-28
Last Update Date:2024-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAMD.205715207R00000X
TXR4223207R00000X, 208M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208M00000XAllopathic & Osteopathic PhysiciansHospitalist
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
LACDS.042366-MDOtherLA BOARD OF PHARMACY
LAMD.205715OtherLSBME
MS03426331Medicaid
LA2342746Medicaid
FG2548292OtherDEA
LA312693YH3UMedicare PIN