Provider Demographics
NPI:1568416014
Name:GAUTAM, SANDEEP (MD)
Entity Type:Individual
Prefix:
First Name:SANDEEP
Middle Name:
Last Name:GAUTAM
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:427 US 31W BYP
Mailing Address - Street 2:
Mailing Address - City:BOWLING GREEN
Mailing Address - State:KY
Mailing Address - Zip Code:42101-1703
Mailing Address - Country:US
Mailing Address - Phone:270-796-8800
Mailing Address - Fax:270-796-9328
Practice Address - Street 1:427 US 31W BYP
Practice Address - Street 2:
Practice Address - City:BOWLING GREEN
Practice Address - State:KY
Practice Address - Zip Code:42101-1703
Practice Address - Country:US
Practice Address - Phone:270-796-8800
Practice Address - Fax:270-796-9328
Is Sole Proprietor?:No
Enumeration Date:2006-05-20
Last Update Date:2022-09-14
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
KY45253207RC0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0001XAllopathic & Osteopathic PhysiciansInternal MedicineClinical Cardiac Electrophysiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100209510Medicaid
KY7100209510Medicaid
MD381070400Medicaid