Provider Demographics
NPI:1518067602
Name:GAUTAM, MICKY K (DO)
Entity Type:Individual
Prefix:DR
First Name:MICKY
Middle Name:K
Last Name:GAUTAM
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
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Mailing Address - Street 1:301 E DIVISION ST
Mailing Address - Street 2:
Mailing Address - City:GREENVILLE
Mailing Address - State:TX
Mailing Address - Zip Code:75402
Mailing Address - Country:US
Mailing Address - Phone:903-453-3376
Mailing Address - Fax:903-454-1149
Practice Address - Street 1:301 DIVISION ST
Practice Address - Street 2:
Practice Address - City:GREENVILLE
Practice Address - State:TX
Practice Address - Zip Code:75401-4101
Practice Address - Country:US
Practice Address - Phone:903-453-3376
Practice Address - Fax:903-454-1149
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-25
Last Update Date:2013-10-01
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
TXL18612084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX8F8971Medicare PIN