Provider Demographics
NPI:1215912522
Name:GANGULY, GAUTAM (MD)
Entity type:Individual
Prefix:
First Name:GAUTAM
Middle Name:
Last Name:GANGULY
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 1:101 E BEVERLY BLVD
Mailing Address - Street 2:206
Mailing Address - City:MONTEBELLO
Mailing Address - State:CA
Mailing Address - Zip Code:90640-4300
Mailing Address - Country:US
Mailing Address - Phone:323-725-7297
Mailing Address - Fax:323-725-0335
Practice Address - Street 1:12291 WASHINGTON BLVD
Practice Address - Street 2:303
Practice Address - City:WHITTIER
Practice Address - State:CA
Practice Address - Zip Code:90606-2500
Practice Address - Country:US
Practice Address - Phone:562-698-6296
Practice Address - Fax:562-693-6752
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-12-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA690582084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAH52836Medicare UPIN