Provider Demographics
NPI:1265650964
Name:GAUTAM, NEETA VERMA (MD)
Entity Type:Individual
Prefix:
First Name:NEETA
Middle Name:VERMA
Last Name:GAUTAM
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:300 PASTEUR DR
Mailing Address - Street 2:
Mailing Address - City:STANFORD
Mailing Address - State:CA
Mailing Address - Zip Code:94305-2200
Mailing Address - Country:US
Mailing Address - Phone:650-498-9000
Mailing Address - Fax:650-736-0647
Practice Address - Street 1:300 PASTEUR DR
Practice Address - Street 2:
Practice Address - City:STANFORD
Practice Address - State:CA
Practice Address - Zip Code:94305-2200
Practice Address - Country:US
Practice Address - Phone:650-498-9000
Practice Address - Fax:650-736-0647
Is Sole Proprietor?:No
Enumeration Date:2007-04-20
Last Update Date:2013-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAC54881207Q00000X
TXK2813207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX105373805Medicaid
TX105373805Medicaid
TX8J3970Medicare Oscar/Certification