Healthcare Provider Details

I. General information

NPI: 1821060807
Provider Name (Legal Business Name): SASHIDHAR V. GANTA M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/03/2006
Last Update Date: 05/10/2023
Certification Date: 05/10/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11851 JOLLYVILLE RD STE 4
AUSTIN TX
78759-2350
US

IV. Provider business mailing address

PO BOX 200185
AUSTIN TX
78720-0185
US

V. Phone/Fax

Practice location:
  • Phone: 512-952-0341
  • Fax:
Mailing address:
  • Phone: 512-244-6452
  • Fax: 512-244-6582

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License NumberM2325
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: