Provider Demographics
NPI:1447320981
Name:GANESAN, MAHAMUNI (MD,)
Entity type:Individual
Prefix:DR
First Name:MAHAMUNI
Middle Name:
Last Name:GANESAN
Suffix:
Gender:M
Credentials:MD,
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:23 W PERRY ST
Mailing Address - Street 2:
Mailing Address - City:TIFFIN
Mailing Address - State:OH
Mailing Address - Zip Code:44883-2243
Mailing Address - Country:US
Mailing Address - Phone:419-448-4171
Mailing Address - Fax:419-448-5551
Practice Address - Street 1:23 W PERRY ST
Practice Address - Street 2:
Practice Address - City:TIFFIN
Practice Address - State:OH
Practice Address - Zip Code:44883-2243
Practice Address - Country:US
Practice Address - Phone:419-448-4171
Practice Address - Fax:419-448-5551
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-09
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35-034118207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0314163Medicaid
0006237OtherCHAMPUS
OH35-034118OtherOHIO STATE MEDICAL BOARD
OH31-1020375-00OtherWORKERS COMP.NO.
DCAG6822022OtherDEA NUMBER
0006237OtherCHAMPUS
OHA75474Medicare UPIN