Provider Demographics
NPI:1669849824
Name:GANGULY, GAUTAM
Entity type:Individual
Prefix:
First Name:GAUTAM
Middle Name:
Last Name:GANGULY
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 640573
Mailing Address - Street 2:STE 146
Mailing Address - City:BEVERLY HILLS
Mailing Address - State:FL
Mailing Address - Zip Code:34464-0573
Mailing Address - Country:US
Mailing Address - Phone:352-746-0600
Mailing Address - Fax:352-746-0607
Practice Address - Street 1:3775 N LECANTO HWY
Practice Address - Street 2:
Practice Address - City:BEVERLY HILLS
Practice Address - State:FL
Practice Address - Zip Code:34465-3559
Practice Address - Country:US
Practice Address - Phone:352-746-0600
Practice Address - Fax:352-746-0607
Is Sole Proprietor?:Yes
Enumeration Date:2015-08-24
Last Update Date:2025-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR019167208D00000X
FLACN1448208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Single Specialty