Provider Demographics
NPI:1407122989
Name:GANGULI, SHANKHO SHUVRO (MD)
Entity type:Individual
Prefix:
First Name:SHANKHO
Middle Name:SHUVRO
Last Name:GANGULI
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 1:1532 LONE OAK RD STE 415
Mailing Address - Street 2:
Mailing Address - City:PADUCAH
Mailing Address - State:KY
Mailing Address - Zip Code:42003-7943
Mailing Address - Country:US
Mailing Address - Phone:270-442-0103
Mailing Address - Fax:
Practice Address - Street 1:1532 LONE OAK RD STE 415
Practice Address - Street 2:
Practice Address - City:PADUCAH
Practice Address - State:KY
Practice Address - Zip Code:42003-7943
Practice Address - Country:US
Practice Address - Phone:270-442-0103
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-03-28
Last Update Date:2025-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KYTP684207RI0011X
WI63869 - 20207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Yes207RI0011XAllopathic & Osteopathic PhysiciansInternal MedicineInterventional Cardiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TNQ057740Medicaid