MEDICARE: GANESH MOORTHY

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	172A00000X	Driver	S70204420	MA

General Provider Information

NPI Number	:	1639038177
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	GANESH MOORTHY

Provider Business Mailing Address
First Line	:	35 GATEHOUSE DR
Second Line	:
City	:	WALTHAM
State	:	MA
Zip	:	02451-1215
Country	:	US
Telephone Number	:	781-839-2848
Fax Number	:

Provider Business Practice Location Address
First Line	:	35 GATEHOUSE DR
Second Line	:
City	:	WALTHAM
State	:	MA
Zip	:	02451-1215
Country	:	US
Telephone Number	:	781-839-2848
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	01/20/2026
Last Update Date	:	01/20/2026

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Directions to “ GANESH MOORTHY ” Practice Location

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