Provider Demographics
NPI:1306876461
Name:GANESH, SIVATHILAKA S (MD)
Entity type:Individual
Prefix:DR
First Name:SIVATHILAKA
Middle Name:S
Last Name:GANESH
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:180 OTAY LAKES RD
Mailing Address - Street 2:SUITE 300
Mailing Address - City:BONITA
Mailing Address - State:CA
Mailing Address - Zip Code:91902-2443
Mailing Address - Country:US
Mailing Address - Phone:619-472-1000
Mailing Address - Fax:619-472-6150
Practice Address - Street 1:180 OTAY LAKES RD
Practice Address - Street 2:SUITE 300
Practice Address - City:BONITA
Practice Address - State:CA
Practice Address - Zip Code:91902-2443
Practice Address - Country:US
Practice Address - Phone:619-472-1000
Practice Address - Fax:619-472-6150
Is Sole Proprietor?:No
Enumeration Date:2006-07-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CAA53266208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics