Provider Demographics
NPI:1235531989
Name:INDIRA GAUTAM MD A PROFESSIONAL MEDICAL CORPORATION
Entity Type:Organization
Organization Name:INDIRA GAUTAM MD A PROFESSIONAL MEDICAL CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:INDIRA
Authorized Official - Middle Name:
Authorized Official - Last Name:GAUTAM
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:337-857-3512
Mailing Address - Street 1:327 IBERIA ST
Mailing Address - Street 2:SUITE 3A
Mailing Address - City:YOUNGSVILLE
Mailing Address - State:LA
Mailing Address - Zip Code:70592-6370
Mailing Address - Country:US
Mailing Address - Phone:337-857-3512
Mailing Address - Fax:
Practice Address - Street 1:327 IBERIA ST
Practice Address - Street 2:SUITE 3A
Practice Address - City:YOUNGSVILLE
Practice Address - State:LA
Practice Address - Zip Code:70592-6370
Practice Address - Country:US
Practice Address - Phone:337-857-3512
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-09-24
Last Update Date:2014-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA15134R207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1191167Medicaid
LA4P857DC90Medicare PIN
LA1191167Medicaid