Provider Demographics
NPI:1801842893
Name:SREEPADA, GANGADHAR S (MD)
Entity Type:Individual
Prefix:DR
First Name:GANGADHAR
Middle Name:S
Last Name:SREEPADA
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 1:660 WHITE PLAINS RD FL 4
Mailing Address - Street 2:
Mailing Address - City:TARRYTOWN
Mailing Address - State:NY
Mailing Address - Zip Code:10591-5139
Mailing Address - Country:US
Mailing Address - Phone:914-984-2546
Mailing Address - Fax:
Practice Address - Street 1:1211 HAMBURG TPKE
Practice Address - Street 2:SUITE 205
Practice Address - City:WAYNE
Practice Address - State:NJ
Practice Address - Zip Code:07470
Practice Address - Country:US
Practice Address - Phone:973-633-0808
Practice Address - Fax:973-633-8811
Is Sole Proprietor?:No
Enumeration Date:2006-05-25
Last Update Date:2019-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA07373300207YX0905X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207YX0905XAllopathic & Osteopathic PhysiciansOtolaryngologyOtolaryngology/Facial Plastic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ092237NEWMedicare PIN
NJI33100Medicare UPIN