Basic Information
| Provider Information | |||||||||
| NPI: | 1225288293 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BANGA | ||||||||
| FirstName: | MADHUMITA | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | CHATTOPADHYAY | ||||||||
| OtherFirstName: | MADHUMITA | ||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | MD | ||||||||
| OtherLastNameType: | 5 | ||||||||
| Mailing Information | |||||||||
| Address1: | PO BOX 66308 | ||||||||
| Address2: | ATTN: BILLING/CREDENTIALING | ||||||||
| City: | HOUSTON | ||||||||
| State: | TX | ||||||||
| PostalCode: | 772666308 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8325485275 | ||||||||
| FaxNumber: | 7135593255 | ||||||||
| Practice Location | |||||||||
| Address1: | 4301 GARTH RD STE 400 | ||||||||
| Address2: | |||||||||
| City: | BAYTOWN | ||||||||
| State: | TX | ||||||||
| PostalCode: | 775213159 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8325485000 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/25/2008 | ||||||||
| LastUpdateDate: | 07/20/2015 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
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| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 036128201 | IL | N | Allopathic & Osteopathic Physicians | Family Medicine | 207Q00000X | P5028 | TX | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 036.128201 | 05 | IL | MEDICAID | 741843 | 01 | TX | LEGACY COMMUNITY HEALTH SERVICES, INC. SITE MEDICARE # | OTHER |