Healthcare Provider Details

I. General information

NPI: 1841337672
Provider Name (Legal Business Name): GANGADHARA R KABBLI MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/31/2007
Last Update Date: 07/31/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1243 PENNSYLVANIA AVE
PINE CITY NY
14871
US

IV. Provider business mailing address

1 GUTHRIE SQ
SAYRE PA
18840-1625
US

V. Phone/Fax

Practice location:
  • Phone: 607-734-6281
  • Fax: 607-734-4409
Mailing address:
  • Phone: 570-888-5858
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License Number262909
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number262909
License Number StateNY

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier1032498220002
Identifier TypeMEDICAID
Identifier StatePA
Identifier Issuer
# 2
Identifier03397880
Identifier TypeMEDICAID
Identifier StateNY
Identifier Issuer

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: