Healthcare Provider Details

I. General information

NPI: 1538104096
Provider Name (Legal Business Name): KEYVAN GANZ DPM
Entity Type: Individual
Gender: Male
Sole Proprietor: N

Provider Other Name: KEYVAN GANJIANPOUR DPM

II. Dates (important events)

Enumeration Date: 06/18/2006
Last Update Date: 08/19/2026
Certification Date: 08/19/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1524 MCHENRY AVE
MODESTO CA
95350-4500
US

IV. Provider business mailing address

PO BOX 58538
WEBSTER TX
77598-8538
US

V. Phone/Fax

Practice location:
  • Phone: 209-722-4842
  • Fax:
Mailing address:
  • Phone: 281-724-5391
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code213ES0000X
TaxonomySports Medicine Podiatrist
License Number1779
License Number StateTX
# 2
Primary TaxonomyN
Taxonomy Code213ES0103X
TaxonomyFoot & Ankle Surgery Podiatrist
License Number0103301393
License Number StateVA
# 3
Primary TaxonomyN
Taxonomy Code213ES0131X
TaxonomyFoot Surgery Podiatrist
License Number1779
License Number StateTX
# 4
Primary TaxonomyY
Taxonomy Code213E00000X
TaxonomyPodiatrist
License Number5728
License Number StateCA
# 5
Primary TaxonomyN
Taxonomy Code213ES0000X
TaxonomySports Medicine Podiatrist
License NumberPOD305010
License Number StateGA
# 6
Primary TaxonomyN
Taxonomy Code213ES0103X
TaxonomyFoot & Ankle Surgery Podiatrist
License Number1779
License Number StateTX
# 7
Primary TaxonomyN
Taxonomy Code213ES0000X
TaxonomySports Medicine Podiatrist
License NumberE5728
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: