Healthcare Provider Details

I. General information

NPI: 1215923701
Provider Name (Legal Business Name): SREENI R. GANGASANI MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/21/2005
Last Update Date: 07/16/2021
Certification Date: 07/16/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

755 WALTHER RD
LAWRENCEVILLE GA
30046-8725
US

IV. Provider business mailing address

755 WALTHER RD
LAWRENCEVILLE GA
30046-8725
US

V. Phone/Fax

Practice location:
  • Phone: 770-962-0399
  • Fax: 770-995-0533
Mailing address:
  • Phone: 770-962-0399
  • Fax: 770-995-0533

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License Number48777
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code207UN0901X
TaxonomyNuclear Cardiology Physician
License Number48777
License Number StateGA
# 3
Primary TaxonomyY
Taxonomy Code207RA0001X
TaxonomyAdvanced Heart Failure and Transplant Cardiology Physician
License Number48777
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: