Provider Demographics
NPI:1548203540
Name:GAUTHIER, ANTHONY R (MD)
Entity Type:Individual
Prefix:DR
First Name:ANTHONY
Middle Name:R
Last Name:GAUTHIER
Suffix:
Gender:M
Credentials:MD
Other - Prefix:DR
Other - First Name:ANTHONY
Other - Middle Name:R
Other - Last Name:GAUTHIER
Other - Suffix:JR
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:1615 WINSTED DR STE 4
Mailing Address - Street 2:
Mailing Address - City:GOSHEN
Mailing Address - State:IN
Mailing Address - Zip Code:46526-4673
Mailing Address - Country:US
Mailing Address - Phone:574-533-8420
Mailing Address - Fax:
Practice Address - Street 1:1615 WINSTED DR STE 4
Practice Address - Street 2:
Practice Address - City:GOSHEN
Practice Address - State:IN
Practice Address - Zip Code:46526-4673
Practice Address - Country:US
Practice Address - Phone:574-533-8420
Practice Address - Fax:574-534-5822
Is Sole Proprietor?:No
Enumeration Date:2006-06-14
Last Update Date:2023-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301079102208800000X
IN01077751A208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
155406OtherGREAT LAKES HLTH PLN
MI3403905992OtherBCBS IND PIN
7405371OtherAETNA PIN
MI4514727-10Medicaid
MI340C910480OtherBCBS GRP PIN
155406OtherGREAT LAKES HLTH PLN
MI0C97625083Medicare PIN
155406OtherGREAT LAKES HLTH PLN
MIP00025772Medicare PIN
G65574Medicare UPIN