Provider Demographics
NPI:1891049342
Name:DEVABRATA GANGULY MD PA
Entity Type:Organization
Organization Name:DEVABRATA GANGULY MD PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:DEVABRATA
Authorized Official - Middle Name:
Authorized Official - Last Name:GANGULY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:903-427-0500
Mailing Address - Street 1:3144 CLARKSVILLE ST
Mailing Address - Street 2:
Mailing Address - City:PARIS
Mailing Address - State:TX
Mailing Address - Zip Code:75460-8002
Mailing Address - Country:US
Mailing Address - Phone:903-784-8700
Mailing Address - Fax:903-427-0503
Practice Address - Street 1:3144 CLARKSVILLE ST
Practice Address - Street 2:
Practice Address - City:PARIS
Practice Address - State:TX
Practice Address - Zip Code:75460-8002
Practice Address - Country:US
Practice Address - Phone:903-784-8700
Practice Address - Fax:903-427-0503
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-11-06
Last Update Date:2016-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXK7287207R00000X, 207RG0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RG0300XAllopathic & Osteopathic PhysiciansInternal MedicineGeriatric MedicineGroup - Single Specialty
No207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX412743OtherMEDICARE PTAN
TX044968802Medicaid
G89838Medicare UPIN