Healthcare Provider Details

I. General information

NPI: 1306135389
Provider Name (Legal Business Name): PRASANTHI PASALA GANDHAM M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/30/2011
Last Update Date: 06/03/2022
Certification Date: 06/03/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

411 E CHESTNUT ST
LOUISVILLE KY
40202
US

IV. Provider business mailing address

PO BOX 776879
CHICAGO IL
60677-6879
US

V. Phone/Fax

Practice location:
  • Phone: 502-588-3400
  • Fax: 502-588-3401
Mailing address:
  • Phone: 502-272-5817
  • Fax: 502-272-5339

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number0116028500
License Number StateVA
# 2
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number47284
License Number StateKY
# 3
Primary TaxonomyN
Taxonomy Code2080P0205X
TaxonomyPediatric Endocrinology Physician
License Number0116028500
License Number StateVA
# 4
Primary TaxonomyN
Taxonomy Code2080P0205X
TaxonomyPediatric Endocrinology Physician
License Number35.134354
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: