Provider Demographics
NPI:1184656605
Name:GANGADHARAN, SIDHARTA P (MD)
Entity Type:Individual
Prefix:
First Name:SIDHARTA
Middle Name:P
Last Name:GANGADHARAN
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 1:124 DAVIS AVE
Mailing Address - Street 2:#3
Mailing Address - City:BROOKLINE
Mailing Address - State:MA
Mailing Address - Zip Code:02445-7634
Mailing Address - Country:US
Mailing Address - Phone:617-632-8383
Mailing Address - Fax:
Practice Address - Street 1:BETH ISRAEL DEACONESS MED CTR
Practice Address - Street 2:110 FRANCIS ST, STE 2A
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02215
Practice Address - Country:US
Practice Address - Phone:617-632-8383
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-07
Last Update Date:2022-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA158136208G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208G00000XAllopathic & Osteopathic PhysiciansThoracic Surgery (Cardiothoracic Vascular Surgery)