Provider Demographics
NPI:1538591623
Name:GANESH, MALINI (MD)
Entity type:Individual
Prefix:
First Name:MALINI
Middle Name:
Last Name:GANESH
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 1:2801 WASHINGTON RD STE 107
Mailing Address - Street 2:#276
Mailing Address - City:AUGUSTA
Mailing Address - State:GA
Mailing Address - Zip Code:30909-2355
Mailing Address - Country:US
Mailing Address - Phone:708-620-6133
Mailing Address - Fax:
Practice Address - Street 1:1228 CHURCH ST STE C
Practice Address - Street 2:
Practice Address - City:SULPHUR SPRINGS
Practice Address - State:TX
Practice Address - Zip Code:75482-2196
Practice Address - Country:US
Practice Address - Phone:512-788-3402
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-07-31
Last Update Date:2024-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036142372207RE0101X
IL036-142372207R00000X, 207RE0101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RE0101XAllopathic & Osteopathic PhysiciansInternal MedicineEndocrinology, Diabetes & Metabolism
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN201373240Medicaid
IN201373240Medicaid