Healthcare Provider Details

I. General information

NPI: 1114219789
Provider Name (Legal Business Name): SASI KRISHNA GHANTA MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/13/2011
Last Update Date: 07/17/2026
Certification Date: 07/17/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

26900 N LAKE PLEASANT PKWY STE 210
PEORIA AZ
85383-1558
US

IV. Provider business mailing address

26900 N LAKE PLEASANT PKWY STE 210
PEORIA AZ
85383-1558
US

V. Phone/Fax

Practice location:
  • Phone: 623-561-3000
  • Fax: 623-561-3009
Mailing address:
  • Phone: 623-561-3000
  • Fax: 623-561-3009

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number44088
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: