Provider Demographics
NPI:1114658267
Name:GAUTAM, PRATIMA (OD)
Entity Type:Individual
Prefix:
First Name:PRATIMA
Middle Name:
Last Name:GAUTAM
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1300 N VERMONT AVE STE 101
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90027-6098
Mailing Address - Country:US
Mailing Address - Phone:323-906-6048
Mailing Address - Fax:323-644-4442
Practice Address - Street 1:1300 N VERMONT AVE STE 101
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90027-6098
Practice Address - Country:US
Practice Address - Phone:323-906-6048
Practice Address - Fax:323-644-4442
Is Sole Proprietor?:No
Enumeration Date:2022-06-20
Last Update Date:2023-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CATLG35439152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA24Medicaid