Provider Demographics
NPI:1659540870
Name:GAUTAMI AGASTYA, MD., INC.
Entity Type:Organization
Organization Name:GAUTAMI AGASTYA, MD., INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:GAUTAMI
Authorized Official - Middle Name:
Authorized Official - Last Name:AGASTYA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:209-833-7555
Mailing Address - Street 1:652 W 11TH ST
Mailing Address - Street 2:SUITE 137
Mailing Address - City:TRACY
Mailing Address - State:CA
Mailing Address - Zip Code:95376-3869
Mailing Address - Country:US
Mailing Address - Phone:209-833-7555
Mailing Address - Fax:209-833-7518
Practice Address - Street 1:652 W 11TH ST
Practice Address - Street 2:SUITE 137
Practice Address - City:TRACY
Practice Address - State:CA
Practice Address - Zip Code:95376-3869
Practice Address - Country:US
Practice Address - Phone:209-833-7555
Practice Address - Fax:209-833-7518
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-02-21
Last Update Date:2013-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAC51385207R00000X
CAA851262083P0500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2083P0500XAllopathic & Osteopathic PhysiciansPreventive MedicinePreventive Medicine/Occupational Environmental MedicineGroup - Multi-Specialty
No207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAG25805Medicare UPIN