Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 152W00000X | Optometrist | 0618002463 | VA |
N | 152WC0802X | Optomitrist - Corneal and Contact Lenses | 0618002463 | VA |
NPI | 1043696305 |
---|---|
Provider Name | Dr. Ganesan Sivaguru |
First Address | Salisbury, MD 21804-1974 |
Second Address | Baileys Crossroads, VA 22041-3119 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 09/08/2015 |
Last Update Date | 09/03/2017 |