Provider Demographics
NPI:1538275904
Name:GAN, AMADO C (MD)
Entity type:Individual
Prefix:
First Name:AMADO
Middle Name:C
Last Name:GAN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:184 STERLING PL
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11217-3307
Mailing Address - Country:US
Mailing Address - Phone:718-783-6860
Mailing Address - Fax:718-783-6861
Practice Address - Street 1:184 STERLING PL
Practice Address - Street 2:BROOKLYN KIDNEY CENTER
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11217-3307
Practice Address - Country:US
Practice Address - Phone:718-780-4601
Practice Address - Fax:718-789-6900
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY113420174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01536410Medicaid
NY36N80Medicare ID - Type Unspecified
NYC10118Medicare UPIN