Healthcare Provider Details

I. General information

NPI: 1891049342
Provider Name (Legal Business Name): DEVABRATA GANGULY MD PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/06/2012
Last Update Date: 06/29/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3144 CLARKSVILLE ST
PARIS TX
75460-8002
US

IV. Provider business mailing address

3144 CLARKSVILLE ST
PARIS TX
75460-8002
US

V. Phone/Fax

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

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name: DEVABRATA GANGULY
Title or Position: OWNER
Credential: MD
Phone: 903-427-0500