Provider Demographics
NPI:1689767261
Name:GANGULY, SIDDHARTHA (MD)
Entity Type:Individual
Prefix:DR
First Name:SIDDHARTHA
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 1:6445 MAIN STREET
Mailing Address - Street 2:OPC FLOOR 24
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77030
Mailing Address - Country:US
Mailing Address - Phone:713-441-9948
Mailing Address - Fax:
Practice Address - Street 1:6445 MAIN STREET
Practice Address - Street 2:OPC FLOOR 24
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77030
Practice Address - Country:US
Practice Address - Phone:713-441-9948
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-02
Last Update Date:2021-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS25693207RH0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RH0000XAllopathic & Osteopathic PhysiciansInternal MedicineHematology
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS100450610AMedicaid
MO208433904Medicaid
MO32125027OtherBCBS KC
KS405970OtherFIRSTGUARD
MO208433904Medicaid
KS405970OtherFIRSTGUARD
KS820000493Medicare ID - Type UnspecifiedRAILROAD MEDICARE