Provider Demographics
NPI:1093750978
Name:PHOOKAN, GAUTAM (MD)
Entity Type:Individual
Prefix:
First Name:GAUTAM
Middle Name:
Last Name:PHOOKAN
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 1:250 N SHADELAND AVE
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46219-4959
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2525 W UNIVERSITY AVE STE 503
Practice Address - Street 2:
Practice Address - City:MUNCIE
Practice Address - State:IN
Practice Address - Zip Code:47303-3409
Practice Address - Country:US
Practice Address - Phone:765-288-0441
Practice Address - Fax:765-282-7879
Is Sole Proprietor?:No
Enumeration Date:2006-06-17
Last Update Date:2022-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN1050143207T00000X
IN01050143A207T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207T00000XAllopathic & Osteopathic PhysiciansNeurological Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN061570015OtherMEDICARE
INM22404245OtherMEDICARE
IN200206470AMedicaid