Healthcare Provider Details

I. General information

NPI: 1366489361
Provider Name (Legal Business Name): MALA SENGUPTA MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/31/2006
Last Update Date: 07/21/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

21298 OLEAN BLVD
PORT CHARLOTTE FL
33952-6705
US

IV. Provider business mailing address

P.O. BOX 741087
ATLANTA, GA - GA
30384-1087
US

V. Phone/Fax

Practice location:
  • Phone: 941-627-6128
  • Fax: 941-764-7071
Mailing address:
  • Phone: 941-627-6128
  • Fax: 941-764-7071

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207ZC0500X
TaxonomyCytopathology Physician
License NumberME43830
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code207ZC0500X
TaxonomyCytopathology Physician
License Number4301057149
License Number StateMI
# 3
Primary TaxonomyN
Taxonomy Code207ZP0102X
TaxonomyAnatomic Pathology & Clinical Pathology Physician
License Number4301057149
License Number StateMI
# 4
Primary TaxonomyY
Taxonomy Code207ZP0102X
TaxonomyAnatomic Pathology & Clinical Pathology Physician
License NumberME43830
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: