Provider Demographics
NPI:1265669683
Name:JAYRAM, GAUTAM (MD)
Entity Type:Individual
Prefix:DR
First Name:GAUTAM
Middle Name:
Last Name:JAYRAM
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:PO BOX 409879
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30384
Mailing Address - Country:US
Mailing Address - Phone:615-261-6000
Mailing Address - Fax:615-261-6052
Practice Address - Street 1:2801 CHARLOTTE AVE
Practice Address - Street 2:
Practice Address - City:NASHVILLE
Practice Address - State:TN
Practice Address - Zip Code:37209
Practice Address - Country:US
Practice Address - Phone:615-250-9200
Practice Address - Fax:615-250-9251
Is Sole Proprietor?:No
Enumeration Date:2009-06-11
Last Update Date:2019-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD74312208800000X
IL125-051491208800000X
TN51217208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD55171600Medicaid
MD55171600Medicaid