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General NPI Number Information
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NPI Number | 1669849824
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Entity Type | Individual
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Provider Name | GAUTAM GANGULY
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Gender | Male
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Dates
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Enumeration Date | 08/24/2015
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Last Update Date | 09/12/2025
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Provider Practice Location Address
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Address Line | 3775 N LECANTO HWY
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City | BEVERLY HILLS
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State | FL
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Zip | 34465-3559
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Country | US
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Telephone | 352-746-0600
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Fax | 352-746-0607
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Provider Business Mailing Address
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Address Line | PO BOX 640573 STE 146
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City | BEVERLY HILLS
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State | FL
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Zip | 34464-0573
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Country | US
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Telephone | 352-746-0600
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Fax | 352-746-0607
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 208D00000X
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Taxonomy Name | General Practice Physician
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License Number | 019167
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License Number State | PR
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Taxonomy #2
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Taxonomy Code | 208D00000X
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Taxonomy Name | General Practice Physician
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License Number | ACN1448
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License Number State | FL
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