Healthcare Provider Details

I. General information

NPI: 1881889657
Provider Name (Legal Business Name): VENKATARAMANAN GANGADHARAN MBBS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/13/2007
Last Update Date: 09/11/2025
Certification Date: 12/19/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

19636 N 27TH AVE STE 401
PHOENIX AZ
85027-4021
US

IV. Provider business mailing address

19636 N 27TH AVE STE 401
PHOENIX AZ
85027-4021
US

V. Phone/Fax

Practice location:
  • Phone: 602-861-1168
  • Fax:
Mailing address:
  • Phone: 602-861-1168
  • Fax: 480-882-5891

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License NumberME120626
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: