Healthcare Provider Details

I. General information

NPI: 1043698673
Provider Name (Legal Business Name): TANEETA MINDY GANGULY MD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/15/2015
Last Update Date: 12/04/2025
Certification Date: 12/04/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3400 SPRUCE STREET 2 RAVDIN
PHILADELPHIA PA
19104-4206
US

IV. Provider business mailing address

3400 SPRUCE ST 3 DULLES
PHILADELPHIA PA
19104-5127
US

V. Phone/Fax

Practice location:
  • Phone: 267-760-7857
  • Fax:
Mailing address:
  • Phone: 215-662-3606
  • Fax: 215-349-5579

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084E0001X
TaxonomyEpilepsy Physician
License NumberMD467235
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: