Basic Information
| Provider Information | |||||||||
| NPI: | 1912262890 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MAHAPATRA | ||||||||
| FirstName: | ANGANA | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | D.O. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | HOMCHAUDHURI | ||||||||
| OtherFirstName: | ANGANA | ||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | D.O. | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 725 IRVING AVE STE 311 | ||||||||
| Address2: | |||||||||
| City: | SYRACUSE | ||||||||
| State: | NY | ||||||||
| PostalCode: | 132101685 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3154645815 | ||||||||
| FaxNumber: | 3154649150 | ||||||||
| Practice Location | |||||||||
| Address1: | 725 IRVING AVE STE 311 | ||||||||
| Address2: | |||||||||
| City: | SYRACUSE | ||||||||
| State: | NY | ||||||||
| PostalCode: | 132101685 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3154645815 | ||||||||
| FaxNumber: | 3154649150 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/07/2012 | ||||||||
| LastUpdateDate: | 12/11/2018 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| AuthorizedOfficialNameSuffix: | |||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 276703-1 | NY | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 04193239 | 05 | NY | MEDICAID |