Provider Demographics
NPI:1437445947
Name:NIGAM, GAURAV (MD)
Entity Type:Individual
Prefix:MR
First Name:GAURAV
Middle Name:
Last Name:NIGAM
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 1:1605 E PLAZA DR
Mailing Address - Street 2:STE 103
Mailing Address - City:TALLAHASSEE
Mailing Address - State:FL
Mailing Address - Zip Code:32308-5327
Mailing Address - Country:US
Mailing Address - Phone:850-878-7271
Mailing Address - Fax:850-878-1509
Practice Address - Street 1:911 STACY BURK DRIVE
Practice Address - Street 2:
Practice Address - City:FLORA
Practice Address - State:IL
Practice Address - Zip Code:62839
Practice Address - Country:US
Practice Address - Phone:618-662-2131
Practice Address - Fax:618-662-1473
Is Sole Proprietor?:No
Enumeration Date:2011-06-22
Last Update Date:2024-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMMD2018-0881207R00000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program