Provider Demographics
NPI:1215992144
Name:GANATRA, VIJAY (MD)
Entity type:Individual
Prefix:
First Name:VIJAY
Middle Name:
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 1:13770 PLANTATION RD STE 4
Mailing Address - Street 2:
Mailing Address - City:FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33912-4460
Mailing Address - Country:US
Mailing Address - Phone:239-561-6263
Mailing Address - Fax:239-561-6264
Practice Address - Street 1:13770 PLANTATION RD
Practice Address - Street 2:UNIT 4
Practice Address - City:FORT MYERS
Practice Address - State:FL
Practice Address - Zip Code:33912-4460
Practice Address - Country:US
Practice Address - Phone:239-561-6263
Practice Address - Fax:239-561-6264
Is Sole Proprietor?:Yes
Enumeration Date:2006-04-20
Last Update Date:2018-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME84201207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLP00854687OtherRAILROAD
FL263735900Medicaid
FLP00854687OtherRAILROAD
FLH34529Medicare UPIN