Provider Demographics
NPI:1316042344
Name:GAUTAM, VIBHA G (MD)
Entity Type:Individual
Prefix:
First Name:VIBHA
Middle Name:G
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 1:393 OCEAN AVE
Mailing Address - Street 2:
Mailing Address - City:NEW LONDON
Mailing Address - State:CT
Mailing Address - Zip Code:06320-4717
Mailing Address - Country:US
Mailing Address - Phone:860-442-5976
Mailing Address - Fax:860-443-5055
Practice Address - Street 1:393 OCEAN AVE
Practice Address - Street 2:
Practice Address - City:NEW LONDON
Practice Address - State:CT
Practice Address - Zip Code:06320-4717
Practice Address - Country:US
Practice Address - Phone:860-442-5976
Practice Address - Fax:860-443-5055
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT021848207RE0101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RE0101XAllopathic & Osteopathic PhysiciansInternal MedicineEndocrinology, Diabetes & Metabolism
Provider Identifiers
StateIdentifier IDID TypeIssuer
XXX4692OtherAETNA
50VGAUTAMCT01OtherBLUE CROSS BLUE SHIELD
CT1218486Medicaid
0611346920001OtherCIGNA
218480OtherCONNECTICARE
OV1683OtherHEALTH NET
SCNL008SCNL008OtherOXFORD HEALTH
SCNL008SCNL008OtherOXFORD HEALTH