Provider Demographics
NPI:1679719751
Name:MICKY GAUTAM, D.O., P.A.
Entity Type:Organization
Organization Name:MICKY GAUTAM, D.O., P.A.
Other - Org Name:PSYCH HEALTH
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER/PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:MICKY
Authorized Official - Middle Name:KEYURNATH
Authorized Official - Last Name:GAUTAM
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:903-783-0864
Mailing Address - Street 1:PO BOX 853072
Mailing Address - Street 2:
Mailing Address - City:RICHARDSON
Mailing Address - State:TX
Mailing Address - Zip Code:75085-3072
Mailing Address - Country:US
Mailing Address - Phone:903-783-0864
Mailing Address - Fax:903-783-1603
Practice Address - Street 1:301 EAST DIVISION STREET
Practice Address - Street 2:
Practice Address - City:GREENVILLE
Practice Address - State:TX
Practice Address - Zip Code:75402-4199
Practice Address - Country:US
Practice Address - Phone:903-454-6000
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-12-19
Last Update Date:2012-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXL18612084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXL1861OtherTX LICENSE