Provider Demographics
NPI:1336721687
Name:GHANTASALA, RAJA SIREESHA (MBBS)
Entity type:Individual
Prefix:DR
First Name:RAJA SIREESHA
Middle Name:
Last Name:GHANTASALA
Suffix:
Gender:F
Credentials:MBBS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5055 E BROADWAY BLVD STE A100
Mailing Address - Street 2:
Mailing Address - City:TUCSON
Mailing Address - State:AZ
Mailing Address - Zip Code:85711-3629
Mailing Address - Country:US
Mailing Address - Phone:520-327-0460
Mailing Address - Fax:
Practice Address - Street 1:1925 W ORANGE GROVE RD STE 109
Practice Address - Street 2:
Practice Address - City:TUCSON
Practice Address - State:AZ
Practice Address - Zip Code:85704-1150
Practice Address - Country:US
Practice Address - Phone:520-751-3675
Practice Address - Fax:520-547-5767
Is Sole Proprietor?:No
Enumeration Date:2021-04-26
Last Update Date:2024-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ73122208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics