Provider Demographics
NPI:1386730059
Name:GURU-PRAKASH, GANJUR H (MD)
Entity type:Individual
Prefix:DR
First Name:GANJUR
Middle Name:H
Last Name:GURU-PRAKASH
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 1:207 HAVEN DR
Mailing Address - Street 2:
Mailing Address - City:DOTHAN
Mailing Address - State:AL
Mailing Address - Zip Code:36301-2919
Mailing Address - Country:US
Mailing Address - Phone:334-793-3319
Mailing Address - Fax:334-793-2291
Practice Address - Street 1:207 HAVEN DR
Practice Address - Street 2:
Practice Address - City:DOTHAN
Practice Address - State:AL
Practice Address - Zip Code:36301-2919
Practice Address - Country:US
Practice Address - Phone:334-793-3319
Practice Address - Fax:334-793-2291
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-04
Last Update Date:2011-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL11357207RN0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL000089193Medicaid
AL000089193Medicaid