Provider Demographics
NPI:1053434258
Name:VIJAY GANATRA, M.D., P.A.
Entity type:Organization
Organization Name:VIJAY GANATRA, M.D., P.A.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:VIJAY
Authorized Official - Middle Name:D
Authorized Official - Last Name:GANATRA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:239-561-6263
Mailing Address - Street 1:13770 PLANTATION RD STE 4
Mailing Address - Street 2:
Mailing Address - City:FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33912-4460
Mailing Address - Country:US
Mailing Address - Phone:239-561-6263
Mailing Address - Fax:239-561-6264
Practice Address - Street 1:13770 PLANTATION RD
Practice Address - Street 2:UNIT 4
Practice Address - City:FORT MYERS
Practice Address - State:FL
Practice Address - Zip Code:33912-4460
Practice Address - Country:US
Practice Address - Phone:239-561-6263
Practice Address - Fax:239-561-6264
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-10
Last Update Date:2018-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME84201207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL263735900Medicaid
FLDQ5776OtherRAILROAD
FL263735900Medicaid
FLH34529Medicare UPIN