Provider Demographics
NPI:1588676407
Name:BHAKTA, GAUTAM SUKHABHAI (MD)
Entity Type:Individual
Prefix:
First Name:GAUTAM
Middle Name:SUKHABHAI
Last Name:BHAKTA
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 1:205 S HALCYON RD
Mailing Address - Street 2:
Mailing Address - City:ARROYO GRANDE
Mailing Address - State:CA
Mailing Address - Zip Code:93420-2602
Mailing Address - Country:US
Mailing Address - Phone:805-474-6110
Mailing Address - Fax:805-474-4020
Practice Address - Street 1:205 S HALCYON RD
Practice Address - Street 2:
Practice Address - City:ARROYO GRANDE
Practice Address - State:CA
Practice Address - Zip Code:93420-2602
Practice Address - Country:US
Practice Address - Phone:805-474-6110
Practice Address - Fax:805-474-4020
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-12
Last Update Date:2014-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG79193208M00000X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No208M00000XAllopathic & Osteopathic PhysiciansHospitalist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAG09648Medicare UPIN