Provider Demographics
NPI:1841337672
Name:KABBLI, GANGADHARA R (MD)
Entity type:Individual
Prefix:
First Name:GANGADHARA
Middle Name:R
Last Name:KABBLI
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 1:1 GUTHRIE SQ
Mailing Address - Street 2:
Mailing Address - City:SAYRE
Mailing Address - State:PA
Mailing Address - Zip Code:18840-1625
Mailing Address - Country:US
Mailing Address - Phone:570-888-5858
Mailing Address - Fax:
Practice Address - Street 1:1243 PENNSYLVANIA AVE
Practice Address - Street 2:
Practice Address - City:PINE CITY
Practice Address - State:NY
Practice Address - Zip Code:14871
Practice Address - Country:US
Practice Address - Phone:607-734-6281
Practice Address - Fax:607-734-4409
Is Sole Proprietor?:No
Enumeration Date:2007-01-31
Last Update Date:2018-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY262909207RC0000X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1032498220002Medicaid
NY03397880Medicaid