Provider Demographics
NPI:1417262395
Name:ABDUL R GANGOO MD PA
Entity Type:Organization
Organization Name:ABDUL R GANGOO MD PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:ABDUL
Authorized Official - Middle Name:RASHID
Authorized Official - Last Name:GANGOO
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:704-739-8946
Mailing Address - Street 1:810 W KING ST
Mailing Address - Street 2:
Mailing Address - City:KINGS MOUNTAIN
Mailing Address - State:NC
Mailing Address - Zip Code:28086-2748
Mailing Address - Country:US
Mailing Address - Phone:704-739-8946
Mailing Address - Fax:704-739-6443
Practice Address - Street 1:810 W KING ST
Practice Address - Street 2:
Practice Address - City:KINGS MOUNTAIN
Practice Address - State:NC
Practice Address - Zip Code:28086-2748
Practice Address - Country:US
Practice Address - Phone:704-739-8946
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-08-16
Last Update Date:2021-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC23024207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC8934472Medicaid
NC8934472Medicaid