Provider Demographics
NPI:1316946841
Name:GANESH, BRIAN R (MD)
Entity type:Individual
Prefix:DR
First Name:BRIAN
Middle Name:R
Last Name:GANESH
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Mailing Address - Street 1:51 PEBBLE BEACH ST
Mailing Address - Street 2:
Mailing Address - City:ABILENE
Mailing Address - State:TX
Mailing Address - Zip Code:79606-5028
Mailing Address - Country:US
Mailing Address - Phone:325-795-9076
Mailing Address - Fax:
Practice Address - Street 1:6200 REGIONAL PLZ
Practice Address - Street 2:SUITE 1450
Practice Address - City:ABILENE
Practice Address - State:TX
Practice Address - Zip Code:79606-5250
Practice Address - Country:US
Practice Address - Phone:325-795-9288
Practice Address - Fax:325-437-1529
Is Sole Proprietor?:Yes
Enumeration Date:2005-07-18
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXL1049207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX080960002Medicaid
TX080960002Medicaid
TXH37423Medicare UPIN