=====================================================
General NPI Number Information
=====================================================
NPI Number | 1053548156
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | SUMATHA GHANTA MD
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/16/2009
-----------------------------------------------------
Last Update Date | 06/11/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 920 OLIVER RD
-----------------------------------------------------
City | MONROE
-----------------------------------------------------
State | LA
-----------------------------------------------------
Zip | 71201-5702
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 318-807-3700
-----------------------------------------------------
Fax | 318-807-0014
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 130 DESIARD ST SUITE 355
-----------------------------------------------------
City | MONROE
-----------------------------------------------------
State | LA
-----------------------------------------------------
Zip | 71201-7319
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 318-807-7875
-----------------------------------------------------
Fax | 318-812-6603
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 390200000X
-----------------------------------------------------
Taxonomy Name | Student in an Organized Health Care Education/Training Program
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number | MD205575
-----------------------------------------------------
License Number State | LA
-----------------------------------------------------