Provider Demographics
NPI:1407062045
Name:GARGOM, AISHA B (MD)
Entity Type:Individual
Prefix:
First Name:AISHA
Middle Name:B
Last Name:GARGOM
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 1:160 S TUTTLE RD
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:OH
Mailing Address - Zip Code:45505-1553
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:160 S TUTTLE RD
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:OH
Practice Address - Zip Code:45505-1553
Practice Address - Country:US
Practice Address - Phone:937-523-9690
Practice Address - Fax:937-523-9698
Is Sole Proprietor?:No
Enumeration Date:2007-05-14
Last Update Date:2015-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301088430207Q00000X
IL036.124871207Q00000X
OH35.126514207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine