Healthcare Provider Details

I. General information

NPI: 1154583607
Provider Name (Legal Business Name): SAILAJA GHANTA MD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/26/2008
Last Update Date: 01/09/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

75 FRANCIS ST
BOSTON MA
02115-6110
US

IV. Provider business mailing address

300 LONGWOOD AVE ENDERS 9
BOSTON MA
02115-5724
US

V. Phone/Fax

Practice location:
  • Phone: 617-582-1212
  • Fax: 617-278-6983
Mailing address:
  • Phone: 617-919-2341
  • Fax: 617-730-0260

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberLP01371
License Number StateRI
# 2
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number247367
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: