Provider Demographics
NPI:1174718076
Name:GANESH, SHANTI PORTIA (MD, MPH)
Entity type:Individual
Prefix:DR
First Name:SHANTI
Middle Name:PORTIA
Last Name:GANESH
Suffix:
Gender:F
Credentials:MD, MPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1540 SPRING VALLEY DR
Mailing Address - Street 2:PM&R DEPARTMENT (117)
Mailing Address - City:HUNTINGTON
Mailing Address - State:WV
Mailing Address - Zip Code:25704-9300
Mailing Address - Country:US
Mailing Address - Phone:304-429-6741
Mailing Address - Fax:
Practice Address - Street 1:1540 SPRING VALLEY DR
Practice Address - Street 2:PM&R DEPARTMENT (117)
Practice Address - City:HUNTINGTON
Practice Address - State:WV
Practice Address - Zip Code:25704-9300
Practice Address - Country:US
Practice Address - Phone:304-429-6741
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-09-13
Last Update Date:2017-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL125050793208100000X
IL036123418208100000X
WV27395208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation