Provider Demographics
NPI:1134151673
Name:GANGULI, KRISTON A (MD)
Entity type:Individual
Prefix:
First Name:KRISTON
Middle Name:A
Last Name:GANGULI
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:20 PEARSON RD
Mailing Address - Street 2:UNIT A
Mailing Address - City:SOMERVILLE
Mailing Address - State:MA
Mailing Address - Zip Code:02144-1314
Mailing Address - Country:US
Mailing Address - Phone:617-519-6000
Mailing Address - Fax:
Practice Address - Street 1:175 CAMBRIDGE ST
Practice Address - Street 2:CRP 575
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02114-2743
Practice Address - Country:US
Practice Address - Phone:617-726-1450
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-07
Last Update Date:2010-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA2280932080P0206X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080P0206XAllopathic & Osteopathic PhysiciansPediatricsPediatric Gastroenterology