Healthcare Provider Details

I. General information

NPI: 1225077274
Provider Name (Legal Business Name): DEVABRATA GANGULY M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/05/2006
Last Update Date: 09/28/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1210 W MAIN ST
CLARKSVILLE TX
75426-3523
US

IV. Provider business mailing address

3144 CLARKSVILLE ST
PARIS TX
75460-8002
US

V. Phone/Fax

Practice location:
  • Phone: 903-427-0500
  • Fax: 903-427-0503
Mailing address:
  • Phone: 903-784-8700
  • Fax: 903-784-7502

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberK7287
License Number StateTX
# 2
Primary TaxonomyN
Taxonomy Code207RG0300X
TaxonomyGeriatric Medicine (Internal Medicine) Physician
License NumberK7287
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: