Provider Demographics
NPI:1477732659
Name:JAYASWAL, GAUTAM (MD)
Entity Type:Individual
Prefix:DR
First Name:GAUTAM
Middle Name:
Last Name:JAYASWAL
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 1:8315 W 119TH TER
Mailing Address - Street 2:
Mailing Address - City:OVERLAND PARK
Mailing Address - State:KS
Mailing Address - Zip Code:66213-1225
Mailing Address - Country:US
Mailing Address - Phone:913-685-3811
Mailing Address - Fax:
Practice Address - Street 1:638 E YOUNG AVE
Practice Address - Street 2:
Practice Address - City:WARRENSBURG
Practice Address - State:MO
Practice Address - Zip Code:64093-9608
Practice Address - Country:US
Practice Address - Phone:913-205-4305
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-10-24
Last Update Date:2021-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA34889207P00000X
WI66431207P00000X
KS0427454207P00000X
CODR.0056136207P00000X
MN60244207P00000X
MO2001031034207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
G74210Medicare UPIN