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: 03/12/2024
Certification Date: 03/12/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2295 PARKLAKE DR NE STE 150
ATLANTA GA
30345-2825
US

IV. Provider business mailing address

2295 PARKLAKE DR NE STE 150
ATLANTA GA
30345-2825
US

V. Phone/Fax

Practice location:
  • Phone: 770-746-4101
  • Fax:
Mailing address:
  • Phone: 770-746-4101
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code213E00000X
TaxonomyPodiatrist
License Number1779
License Number StateTX
# 2
Primary TaxonomyN
Taxonomy Code213E00000X
TaxonomyPodiatrist
License Number901365
License Number StateFL
# 3
Primary TaxonomyN
Taxonomy Code213E00000X
TaxonomyPodiatrist
License Number0167
License Number StateAZ
# 4
Primary TaxonomyN
Taxonomy Code213ES0000X
TaxonomySports Medicine Podiatrist
License NumberE5728
License Number StateCA
# 5
Primary TaxonomyN
Taxonomy Code213ES0103X
TaxonomyFoot & Ankle Surgery Podiatrist
License Number0103301393
License Number StateVA
# 6
Primary TaxonomyY
Taxonomy Code213ES0000X
TaxonomySports Medicine Podiatrist
License NumberPOD305010
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: