Healthcare Provider Details

I. General information

NPI: 1437732096
Provider Name (Legal Business Name): ABHINAV REDDY GANGASANI
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/03/2021
Last Update Date: 05/01/2025
Certification Date: 05/01/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

111 E 210TH ST
BRONX NY
10467-2401
US

IV. Provider business mailing address

12 ELDORADO WAY
MONROE NJ
08831-4510
US

V. Phone/Fax

Practice location:
  • Phone: 718-920-4383
  • Fax: 718-653-2367
Mailing address:
  • Phone: 732-207-5442
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License Number25MA12650700
License Number StateNJ
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: