Basic Information
| Provider Information | |||||||||
| NPI: | 1639581655 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | GANGU | ||||||||
| FirstName: | SHASHIKANTH | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1 BROOKDALE PLZ | ||||||||
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| City: | BROOKLYN | ||||||||
| State: | NY | ||||||||
| PostalCode: | 112123139 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7182405893 | ||||||||
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| Practice Location | |||||||||
| Address1: | 3001 W DR MARTIN LUTHER KING JR BLVD FL 1 | ||||||||
| Address2: | |||||||||
| City: | TAMPA | ||||||||
| State: | FL | ||||||||
| PostalCode: | 336076307 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8133570711 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 05/26/2014 | ||||||||
| LastUpdateDate: | 05/01/2019 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2080P0203X | ME131651 | FL | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pediatrics | Pediatric Critical Care Medicine |
No ID Information.