Healthcare Provider Details

I. General information

NPI: 1871997924
Provider Name (Legal Business Name): GANGULY ASSOCIATES MD PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/17/2014
Last Update Date: 10/17/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

140 BENCHLEY PL FRNT 1
BRONX NY
10475-3502
US

IV. Provider business mailing address

29 CHICKEN VALLEY RD
GLEN HEAD NY
11545-2103
US

V. Phone/Fax

Practice location:
  • Phone: 718-379-1800
  • Fax: 718-320-0749
Mailing address:
  • Phone: 516-759-1661
  • Fax: 718-320-0749

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number147280
License Number StateNY

VIII. Authorized Official

Name: RAKHI GANGULY
Title or Position: PRESIDENT
Credential: M.D.,
Phone: 718-379-1800