=====================================================
General NPI Number Information
=====================================================
NPI Number | 1912262890
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | ANGANA MAHAPATRA D.O.
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/07/2012
-----------------------------------------------------
Last Update Date | 12/11/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 725 IRVING AVE STE 311
-----------------------------------------------------
City | SYRACUSE
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 13210-1685
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 315-464-5815
-----------------------------------------------------
Fax | 315-464-9150
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 725 IRVING AVE STE 311
-----------------------------------------------------
City | SYRACUSE
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 13210-1685
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 315-464-5815
-----------------------------------------------------
Fax | 315-464-9150
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number | 276703-1
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------