Provider Demographics
NPI:1649237314
Name:MOGILISHETTY, GAUTHAM (MD)
Entity Type:Individual
Prefix:
First Name:GAUTHAM
Middle Name:
Last Name:MOGILISHETTY
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 1:3400 LEE BLVD STE 112
Mailing Address - Street 2:
Mailing Address - City:LEHIGH ACRES
Mailing Address - State:FL
Mailing Address - Zip Code:33971-1309
Mailing Address - Country:US
Mailing Address - Phone:239-939-0999
Mailing Address - Fax:239-939-1070
Practice Address - Street 1:3400 LEE BLVD STE 112
Practice Address - Street 2:
Practice Address - City:LEHIGH ACRES
Practice Address - State:FL
Practice Address - Zip Code:33971-1309
Practice Address - Country:US
Practice Address - Phone:239-939-0999
Practice Address - Fax:239-939-1070
Is Sole Proprietor?:No
Enumeration Date:2006-04-27
Last Update Date:2022-11-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35-084821207R00000X, 207RN0300X
FLME129188207RN0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrology
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY64091192Medicaid
IN200207710Medicaid
OH2521542Medicaid
KY64091192Medicaid
OHMO4140121Medicare PIN
KY64091192Medicaid