Provider Demographics
NPI:1760458228
Name:GANGADHARAN, SANDEEP
Entity Type:Individual
Prefix:DR
First Name:SANDEEP
Middle Name:
Last Name:GANGADHARAN
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 1:2647 BROADWAY
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10025-5063
Mailing Address - Country:US
Mailing Address - Phone:212-961-1087
Mailing Address - Fax:
Practice Address - Street 1:COLUMBIA UNIVERSITY DEPARTMENT PEDIATRIC
Practice Address - Street 2:3959 BROADWAY
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10032
Practice Address - Country:US
Practice Address - Phone:212-304-7250
Practice Address - Fax:212-544-1974
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-02-24
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY2292742080P0203X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080P0203XAllopathic & Osteopathic PhysiciansPediatricsPediatric Critical Care Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02705168Medicaid
NYI47664Medicare UPIN
NY352AU1Medicare ID - Type Unspecified