Provider Demographics
NPI:1881224103
Name:GANGAL, DIANA
Entity Type:Individual
Prefix:
First Name:DIANA
Middle Name:
Last Name:GANGAL
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:173 DOVER GRN
Mailing Address - Street 2:
Mailing Address - City:STATEN ISLAND
Mailing Address - State:NY
Mailing Address - Zip Code:10312-1710
Mailing Address - Country:US
Mailing Address - Phone:646-379-4028
Mailing Address - Fax:
Practice Address - Street 1:173 DOVER GRN
Practice Address - Street 2:
Practice Address - City:STATEN ISLAND
Practice Address - State:NY
Practice Address - Zip Code:10312-1710
Practice Address - Country:US
Practice Address - Phone:646-379-4028
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-01-26
Last Update Date:2020-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY2773882174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist