Healthcare Provider Details

I. General information

NPI: 1033185772
Provider Name (Legal Business Name): JYOTSOM BIPIN GANATRA MD MPU
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/23/2006
Last Update Date: 12/14/2021
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

250 RIVER RD
MANCHESTER NH
03104-2423
US

IV. Provider business mailing address

250 RIVER RD
MANCHESTER NH
03104-2423
US

V. Phone/Fax

Practice location:
  • Phone: 603-668-2020
  • Fax: 603-668-0881
Mailing address:
  • Phone: 603-668-2020
  • Fax: 603-668-0881

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207W00000X
TaxonomyOphthalmology Physician
License Number12903
License Number StateNH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: