Provider Demographics
NPI:1538113733
Name:MALKANI, GAUTAM (MD)
Entity Type:Individual
Prefix:
First Name:GAUTAM
Middle Name:
Last Name:MALKANI
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 1:500 MEDICAL CENTER BLVD
Mailing Address - Street 2:
Mailing Address - City:WEBSTER
Mailing Address - State:TX
Mailing Address - Zip Code:77598-4220
Mailing Address - Country:US
Mailing Address - Phone:281-554-4300
Mailing Address - Fax:281-554-4355
Practice Address - Street 1:450 MEDICAL CENTER BLVD
Practice Address - Street 2:STE 600
Practice Address - City:WEBSTER
Practice Address - State:TX
Practice Address - Zip Code:77598-4234
Practice Address - Country:US
Practice Address - Phone:713-852-1565
Practice Address - Fax:866-638-6744
Is Sole Proprietor?:No
Enumeration Date:2006-05-20
Last Update Date:2010-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL26579208000000X, 2080P0203X
TXM81552080P0203X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
No2080P0203XAllopathic & Osteopathic PhysiciansPediatricsPediatric Critical Care Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX197703502Medicaid
AL7600062OtherUNITED HEALTH CARE
AL51529983OtherBLUE CROSS
AL009932429Medicaid
MS02588701Medicaid
TXP00765175OtherRAILROAD MEDICARE
TX8F9102Medicare PIN
AL51529983OtherBLUE CROSS
AL7600062OtherUNITED HEALTH CARE
AL009932429Medicaid