Provider Demographics
NPI:1811023492
Name:GANGULI, SUVRANU (MD)
Entity Type:Individual
Prefix:DR
First Name:SUVRANU
Middle Name:
Last Name:GANGULI
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:801 ALBANY ST
Mailing Address - Street 2:FL G
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02119-2560
Mailing Address - Country:US
Mailing Address - Phone:617-414-5405
Mailing Address - Fax:617-414-6031
Practice Address - Street 1:840 HARRISON AVE
Practice Address - Street 2:
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02118-2905
Practice Address - Country:US
Practice Address - Phone:617-638-6610
Practice Address - Fax:617-638-6616
Is Sole Proprietor?:No
Enumeration Date:2007-02-26
Last Update Date:2020-10-06
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MA2309202085R0204X, 2085R0204X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0204XAllopathic & Osteopathic PhysiciansRadiologyVascular & Interventional Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA110075830AMedicaid