Provider Demographics
NPI:1376846907
Name:GAUTAM, GAGAN (MD, MCH)
Entity Type:Individual
Prefix:DR
First Name:GAGAN
Middle Name:
Last Name:GAUTAM
Suffix:
Gender:M
Credentials:MD, MCH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6033 N SHERIDAN RD
Mailing Address - Street 2:APT 14 D
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60660-3003
Mailing Address - Country:US
Mailing Address - Phone:773-575-4165
Mailing Address - Fax:
Practice Address - Street 1:5841 S MARYLAND AVE
Practice Address - Street 2:J 664
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60637-1447
Practice Address - Country:US
Practice Address - Phone:773-575-4165
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-12-21
Last Update Date:2010-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL125.055629208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology