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General NPI Number Information
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NPI Number | 1336721687
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Entity Type | Individual
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Provider Name | RAJA SIREESHA GHANTASALA MBBS
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Gender | Female
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Dates
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Enumeration Date | 04/26/2021
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Last Update Date | 12/19/2024
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Provider Practice Location Address
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Address Line | 1925 W ORANGE GROVE RD STE 109
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City | TUCSON
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State | AZ
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Zip | 85704-1150
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Country | US
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Telephone | 520-751-3675
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Fax | 520-547-5767
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Provider Business Mailing Address
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Address Line | 5055 E BROADWAY BLVD STE A100
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City | TUCSON
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State | AZ
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Zip | 85711-3629
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Country | US
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Telephone | 520-327-0460
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 208000000X
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Taxonomy Name | Pediatrics Physician
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License Number | 73122
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License Number State | AZ
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