Provider Demographics
NPI:1669849824
Name:GANGULY, GAUTAM
Entity Type:Individual
Prefix:
First Name:GAUTAM
Middle Name:
Last Name:GANGULY
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1542 KINGSLEY AVE
Mailing Address - Street 2:STE 146
Mailing Address - City:ORANGE PARK
Mailing Address - State:FL
Mailing Address - Zip Code:32073-4547
Mailing Address - Country:US
Mailing Address - Phone:201-294-0073
Mailing Address - Fax:
Practice Address - Street 1:1542 KINGSLEY AVE STE 146
Practice Address - Street 2:
Practice Address - City:ORANGE PARK
Practice Address - State:FL
Practice Address - Zip Code:32073-4547
Practice Address - Country:US
Practice Address - Phone:904-269-2990
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-08-24
Last Update Date:2022-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLACN1448208D00000X
PR019167208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Single Specialty