Provider Demographics
NPI:1619372182
Name:GAUTAM, SUDARSON
Entity Type:Individual
Prefix:MR
First Name:SUDARSON
Middle Name:
Last Name:GAUTAM
Suffix:
Gender:M
Credentials:
Other - Prefix:MR
Other - First Name:SUDHARSHAN
Other - Middle Name:
Other - Last Name:GAUTAM
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:OTR/L
Mailing Address - Street 1:40 ELMDATE STREET
Mailing Address - Street 2:APT 2
Mailing Address - City:WEST SPRINGFIELD
Mailing Address - State:MA
Mailing Address - Zip Code:01089
Mailing Address - Country:US
Mailing Address - Phone:413-727-1376
Mailing Address - Fax:
Practice Address - Street 1:40 ELMDALE ST
Practice Address - Street 2:APT 2
Practice Address - City:WEST SPRINGFIELD
Practice Address - State:MA
Practice Address - Zip Code:01089-2706
Practice Address - Country:US
Practice Address - Phone:413-727-1376
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-10-27
Last Update Date:2014-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA11319225XP0019X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225XP0019XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPhysical Rehabilitation