Provider Demographics
NPI:1285651620
Name:GANGULI, CHANDANA (MD)
Entity Type:Individual
Prefix:
First Name:CHANDANA
Middle Name:
Last Name:GANGULI
Suffix:
Gender:F
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:PO BOX 19305
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28219-9305
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1021 MOREHEAD MEDICAL DR
Practice Address - Street 2:STE A
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28204-2990
Practice Address - Country:US
Practice Address - Phone:980-442-2000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-15
Last Update Date:2023-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC200300038207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC89133PAMedicaid
NC44336OtherBCBS
NC1285651620Medicaid
SCN00035Medicaid
NC2012395Medicare PIN
NC2012395AMedicare PIN
NCNCH231AMedicare PIN
NC1285651620Medicaid
NC2012395BMedicare PIN
NC11248265Medicare PIN
NC2012395CMedicare PIN