Healthcare Provider Details

I. General information

NPI: 1376747618
Provider Name (Legal Business Name): SUDHA GANNE MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/12/2007
Last Update Date: 07/15/2026
Certification Date: 07/15/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

103 PARKER RD
WEST LONG BRANCH NJ
07764-1009
US

IV. Provider business mailing address

103 PARKER RD
WEST LONG BRANCH NJ
07764-1009
US

V. Phone/Fax

Practice location:
  • Phone: 732-222-0307
  • Fax: 732-222-0394
Mailing address:
  • Phone: 732-222-0307
  • Fax: 732-222-0394

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number25MA07676300
License Number StateNJ
# 2
Primary TaxonomyY
Taxonomy Code207RE0101X
TaxonomyEndocrinology, Diabetes & Metabolism Physician
License Number25MA07676300
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: