Provider Demographics
NPI:1639116742
Name:DESAI, GAUTAM T (MD)
Entity Type:Individual
Prefix:
First Name:GAUTAM
Middle Name:T
Last Name:DESAI
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Mailing Address - Street 1:447 ROUTE 10
Mailing Address - Street 2:SUITE 2
Mailing Address - City:RANDOLPH
Mailing Address - State:NJ
Mailing Address - Zip Code:07869
Mailing Address - Country:US
Mailing Address - Phone:973-361-4555
Mailing Address - Fax:973-361-6360
Practice Address - Street 1:447 RT 10
Practice Address - Street 2:SUITE 2
Practice Address - City:RANDOLPH
Practice Address - State:NJ
Practice Address - Zip Code:07869
Practice Address - Country:US
Practice Address - Phone:973-361-4555
Practice Address - Fax:973-361-6360
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-05-31
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NJ25MA03468300207R00000X, 207RP1001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Not Answered207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ2982803Medicaid
NJ197467Medicare ID - Type Unspecified
C59703Medicare UPIN