Healthcare Provider Details

I. General information

NPI: 1336721687
Provider Name (Legal Business Name): RAJA SIREESHA GHANTASALA MBBS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/26/2021
Last Update Date: 12/19/2024
Certification Date: 12/19/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1925 W ORANGE GROVE RD STE 109
TUCSON AZ
85704-1150
US

IV. Provider business mailing address

5055 E BROADWAY BLVD STE A100
TUCSON AZ
85711-3629
US

V. Phone/Fax

Practice location:
  • Phone: 520-751-3675
  • Fax: 520-547-5767
Mailing address:
  • Phone: 520-327-0460
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number73122
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: