Provider Demographics
NPI:1639507940
Name:TOMAR, GAUTAM (MS)
Entity Type:Individual
Prefix:
First Name:GAUTAM
Middle Name:
Last Name:TOMAR
Suffix:
Gender:M
Credentials:MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1155 MALABAR RD NE
Mailing Address - Street 2:SUITE 1
Mailing Address - City:PALM BAY
Mailing Address - State:FL
Mailing Address - Zip Code:32907-3245
Mailing Address - Country:US
Mailing Address - Phone:321-409-5777
Mailing Address - Fax:321-409-5888
Practice Address - Street 1:1155 MALABAR RD NE
Practice Address - Street 2:SUITE 1
Practice Address - City:PALM BAY
Practice Address - State:FL
Practice Address - Zip Code:32907-3245
Practice Address - Country:US
Practice Address - Phone:321-409-5777
Practice Address - Fax:321-409-5888
Is Sole Proprietor?:Yes
Enumeration Date:2013-10-23
Last Update Date:2014-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY036080225100000X
FL28842225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist