Healthcare Provider Details

I. General information

NPI: 1801648191
Provider Name (Legal Business Name): SANDEEPAN GANGULY
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/02/2024
Last Update Date: 08/02/2026
Certification Date: 08/02/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3900 W CAPITOL AVE
LITTLE ROCK AR
72205-5502
US

IV. Provider business mailing address

3900 W CAPITOL AVE
LITTLE ROCK AR
72205-5502
US

V. Phone/Fax

Practice location:
  • Phone: 501-664-4568
  • Fax:
Mailing address:
  • Phone: 501-664-4568
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2085R0205X
TaxonomyRadiological Physics Physician
License NumberP126129
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: