Provider Demographics
NPI:1437879624
Name:GAUTAM, DIPENDRA
Entity Type:Individual
Prefix:
First Name:DIPENDRA
Middle Name:
Last Name:GAUTAM
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:113 RIVERWALK BLVD S
Mailing Address - Street 2:SUITE 111-50
Mailing Address - City:MADERA
Mailing Address - State:CA
Mailing Address - Zip Code:93636
Mailing Address - Country:US
Mailing Address - Phone:703-626-9334
Mailing Address - Fax:
Practice Address - Street 1:113 RIVERWALK BLVD S
Practice Address - Street 2:SUITE 111-50
Practice Address - City:MADERA
Practice Address - State:CA
Practice Address - Zip Code:93636
Practice Address - Country:US
Practice Address - Phone:703-626-9334
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-08-30
Last Update Date:2024-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPT2982522251G0304X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251G0304XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGeriatrics