Healthcare Provider Details

I. General information

NPI: 1609453406
Provider Name (Legal Business Name): PRAJESH GONGAL M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/26/2021
Last Update Date: 08/07/2025
Certification Date: 06/11/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 MEDICAL CENTER DR
LEBANON NH
03756-1000
US

IV. Provider business mailing address

601 ELMWOOD AVENUE BOX679-A
ROCHESTER NY
14642
US

V. Phone/Fax

Practice location:
  • Phone: 603-650-7515
  • Fax:
Mailing address:
  • Phone: 585-275-4290
  • Fax: 585-473-1573

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number33137
License Number StateNH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: