Healthcare Provider Details

I. General information

NPI: 1255328266
Provider Name (Legal Business Name): JYOTI B GANJI MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/04/2005
Last Update Date: 11/23/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

80 B VETERANS BLVD
ACOMA NM
87034
US

IV. Provider business mailing address

PO BOX 130
SAN FIDEL NM
87049-0130
US

V. Phone/Fax

Practice location:
  • Phone: 505-552-5300
  • Fax: 505-552-5490
Mailing address:
  • Phone: 505-552-5300
  • Fax: 505-552-5490

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number06964R
License Number StateLA
# 2
Primary TaxonomyN
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number22011
License Number StateKS
# 3
Primary TaxonomyN
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number13972
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: