Individual
GURU PRASAD GHANTA
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
Man
Credential
M.D.
Contact information
Practice address
1015 W FERTITTA BLVD, LEESVILLE, LA 71446-4646
(337) 239-4130
(337) 238-4104
Mailing address
1015 W FERTITTA BLVD, LEESVILLE, LA 71446-4646
(337) 239-4130
(337) 238-4104
Taxonomy
Speciality
Code
Description
License number
State
174400000X
Specialist
Primary
05477R
LA
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
05477R
LA. STATE LICENSE
LA
05
—
1313998
—
LA
01
—
720946706
TAX ID #
LA
Enumeration date
01/10/2006
Last updated
01/13/2011
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