Provider Demographics
NPI:1225077274
Name:GANGULY, DEVABRATA (MD)
Entity Type:Individual
Prefix:DR
First Name:DEVABRATA
Middle Name:
Last Name:GANGULY
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 1:3144 CLARKSVILLE ST
Mailing Address - Street 2:
Mailing Address - City:PARIS
Mailing Address - State:TX
Mailing Address - Zip Code:75460-8002
Mailing Address - Country:US
Mailing Address - Phone:903-784-8700
Mailing Address - Fax:903-784-7502
Practice Address - Street 1:1210 W MAIN ST
Practice Address - Street 2:
Practice Address - City:CLARKSVILLE
Practice Address - State:TX
Practice Address - Zip Code:75426-3523
Practice Address - Country:US
Practice Address - Phone:903-427-0500
Practice Address - Fax:903-427-0503
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-05
Last Update Date:2015-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXK7287207R00000X, 207RG0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No207RG0300XAllopathic & Osteopathic PhysiciansInternal MedicineGeriatric Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX0096JEOtherBCBS
TX110247089OtherRAIL ROAD MEDICARE
TX044968802Medicaid
TX0096JEOtherBCBS
TX044968802Medicaid