1831172725 NPI number — DR. MANJUSHREE GAUTAM M.D.

Table of content: DR. MANJUSHREE GAUTAM M.D. (NPI 1831172725)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1831172725 NPI number — DR. MANJUSHREE GAUTAM M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
GAUTAM
Provider First Name:
MANJUSHREE
Provider Middle Name:
Provider Name Prefix Text:
DR.
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:
1831172725
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/21/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1250 8TH AVE
Provider Second Line Business Mailing Address:
SUITE 515
Provider Business Mailing Address City Name:
FORT WORTH
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
76104-4124
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
817-922-4675
Provider Business Mailing Address Fax Number:
817-922-4645

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1250 8TH AVE
Provider Second Line Business Practice Location Address:
SUITE 515
Provider Business Practice Location Address City Name:
FORT WORTH
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
76104-4124
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
817-922-4675
Provider Business Practice Location Address Fax Number:
817-922-4645
Provider Enumeration Date:
11/23/2005

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: 207RI0008X , with the licence number:  33778 , registered in the state of AZ ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207RG0100X , with the licence number: N6309 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 207RT0003X , with the licence number: N6309 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: 8BN847 . This is a "BCBSTX" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: 217199301 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".
  • Identifier: 935554 , issued by the state of ( AZ ) . This identifiers is of the category "MEDICAID".
  • Identifier: 86080015085259D008 . This is a "TRIWEST" identifier , issued by the state of ( AZ ) . This identifiers is of the category "OTHER".
  • Identifier: P00278312 . This is a "RAILROAD MEDICARE" identifier , issued by the state of ( AZ ) . This identifiers is of the category "OTHER".




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