Healthcare Provider Details

I. General information

NPI: 1134413651
Provider Name (Legal Business Name): VISHNU GANTA M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/01/2011
Last Update Date: 03/05/2026
Certification Date: 03/05/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

500 MARTHA JEFFERSON DR
CHARLOTTESVILLE VA
22911-4668
US

IV. Provider business mailing address

115 GLENEAGLE
CORTLAND OH
44410-8729
US

V. Phone/Fax

Practice location:
  • Phone: 434-654-7955
  • Fax: 434-654-7944
Mailing address:
  • Phone: 615-525-6167
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207ZP0102X
TaxonomyAnatomic Pathology & Clinical Pathology Physician
License Number0101288376
License Number StateVA
# 2
Primary TaxonomyN
Taxonomy Code207ZP0102X
TaxonomyAnatomic Pathology & Clinical Pathology Physician
License NumberMD446742
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: