Provider Demographics
NPI:1356312516
Name:AGASTYA, GAUTAMI (MD)
Entity Type:Individual
Prefix:
First Name:GAUTAMI
Middle Name:
Last Name:AGASTYA
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 1:652 W 11TH ST
Mailing Address - Street 2:SUITE 137
Mailing Address - City:TRACY
Mailing Address - State:CA
Mailing Address - Zip Code:95376-3869
Mailing Address - Country:US
Mailing Address - Phone:209-833-7555
Mailing Address - Fax:209-833-7518
Practice Address - Street 1:652 W 11TH ST
Practice Address - Street 2:SUITE 137
Practice Address - City:TRACY
Practice Address - State:CA
Practice Address - Zip Code:95376-3869
Practice Address - Country:US
Practice Address - Phone:209-833-7555
Practice Address - Fax:209-833-7518
Is Sole Proprietor?:Yes
Enumeration Date:2006-01-27
Last Update Date:2013-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAC51385207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00C513850Medicaid
CA00C513850Medicaid
G25805Medicare UPIN