Provider Demographics
NPI:1144202805
Name:GORIGANTI, MAHENDER R (MD)
Entity Type:Individual
Prefix:DR
First Name:MAHENDER
Middle Name:R
Last Name:GORIGANTI
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1000 E GENESEE ST
Mailing Address - Street 2:
Mailing Address - City:SYRACUSE
Mailing Address - State:NY
Mailing Address - Zip Code:13210-1853
Mailing Address - Country:US
Mailing Address - Phone:315-423-4155
Mailing Address - Fax:315-423-4199
Practice Address - Street 1:1000 E GENESEE ST STE 100A
Practice Address - Street 2:
Practice Address - City:SYRACUSE
Practice Address - State:NY
Practice Address - Zip Code:13210-1853
Practice Address - Country:US
Practice Address - Phone:315-423-4155
Practice Address - Fax:315-423-4199
Is Sole Proprietor?:Yes
Enumeration Date:2005-11-17
Last Update Date:2007-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY210930208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02283232Medicaid
NY522371740OtherEIN
NYG74134Medicare UPIN
NY02283232Medicaid
NYAA1356Medicare PIN