Provider Demographics
NPI:1922442359
Name:SANYAL, SAMUDRAGUPTA (MD)
Entity Type:Individual
Prefix:DR
First Name:SAMUDRAGUPTA
Middle Name:
Last Name:SANYAL
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 1:232 MERRICK RD
Mailing Address - Street 2:
Mailing Address - City:LYNBROOK
Mailing Address - State:NY
Mailing Address - Zip Code:11563-2623
Mailing Address - Country:US
Mailing Address - Phone:516-594-5961
Mailing Address - Fax:516-256-5556
Practice Address - Street 1:30 FRANKLIN AVE
Practice Address - Street 2:
Practice Address - City:FRANKLIN SQUARE
Practice Address - State:NY
Practice Address - Zip Code:11010-2527
Practice Address - Country:US
Practice Address - Phone:516-352-0253
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-04-29
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY290850261QU0200X, 390200000X, 208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Multi-Specialty
No261QU0200XAmbulatory Health Care FacilitiesClinic/CenterUrgent CareGroup - Multi-Specialty
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program