1316042344 NPI number — VIBHA G GAUTAM M.D.

Table of content: VIBHA G GAUTAM M.D. (NPI 1316042344)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1316042344 NPI number — VIBHA G GAUTAM M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
GAUTAM
Provider First Name:
VIBHA
Provider Middle Name:
G
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
M.D.
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1316042344
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
393 OCEAN AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
NEW LONDON
Provider Business Mailing Address State Name:
CT
Provider Business Mailing Address Postal Code:
06320-4717
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
860-442-5976
Provider Business Mailing Address Fax Number:
860-443-5055

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
393 OCEAN AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
NEW LONDON
Provider Business Practice Location Address State Name:
CT
Provider Business Practice Location Address Postal Code:
06320-4717
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
860-442-5976
Provider Business Practice Location Address Fax Number:
860-443-5055
Provider Enumeration Date:
09/14/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207RE0101X , with the licence number:  021848 , registered in the state of CT ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: XXX4692 . This is a "AETNA" identifier . This identifiers is of the category "OTHER".
  • Identifier: 50VGAUTAMCT01 . This is a "BLUE CROSS BLUE SHIELD" identifier . This identifiers is of the category "OTHER".
  • Identifier: 1218486 , issued by the state of ( CT ) . This identifiers is of the category "MEDICAID".
  • Identifier: 0611346920001 . This is a "CIGNA" identifier . This identifiers is of the category "OTHER".
  • Identifier: 218480 . This is a "CONNECTICARE" identifier . This identifiers is of the category "OTHER".
  • Identifier: OV1683 . This is a "HEALTH NET" identifier . This identifiers is of the category "OTHER".
  • Identifier: SCNL008SCNL008 . This is a "OXFORD HEALTH" identifier . This identifiers is of the category "OTHER".




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