Provider Demographics
NPI:1316101272
Name:GANESHAN, DEEPA (MD)
Entity type:Individual
Prefix:
First Name:DEEPA
Middle Name:
Last Name:GANESHAN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12398 FM 423 STE 600
Mailing Address - Street 2:
Mailing Address - City:FRISCO
Mailing Address - State:TX
Mailing Address - Zip Code:75033-0158
Mailing Address - Country:US
Mailing Address - Phone:214-494-4622
Mailing Address - Fax:214-494-4609
Practice Address - Street 1:12398 FM 423 STE 600
Practice Address - Street 2:
Practice Address - City:FRISCO
Practice Address - State:TX
Practice Address - Zip Code:75033-0158
Practice Address - Country:US
Practice Address - Phone:214-494-4622
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-07-10
Last Update Date:2022-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ME017942208000000X
NM2002-0360208000000X
TXR3514208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM201041812Medicaid
TX406890001Medicaid
ME433096999Medicaid