Healthcare Provider Details

I. General information

NPI: 1508204009
Provider Name (Legal Business Name): THIYAGU GANESAN MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/06/2013
Last Update Date: 10/24/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5730 PACKARD AVENUE SUITE NO: 500
MARYSVILLE CA
95993
US

IV. Provider business mailing address

5730 PACKARD AVE SUITE 500
MARYSVILLE CA
95901-7118
US

V. Phone/Fax

Practice location:
  • Phone: 530-749-3242
  • Fax: 530-749-3248
Mailing address:
  • Phone: 530-749-3242
  • Fax: 530-749-3248

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberA140735
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: