Provider Demographics
NPI:1700185667
Name:AGGARWAL, GAUTAM (MD)
Entity Type:Individual
Prefix:DR
First Name:GAUTAM
Middle Name:
Last Name:AGGARWAL
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4041 N CENTRAL AVE
Mailing Address - Street 2:BLDG C
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85012-3313
Mailing Address - Country:US
Mailing Address - Phone:602-279-5262
Mailing Address - Fax:602-279-5390
Practice Address - Street 1:4131 N 24TH ST
Practice Address - Street 2:STE. B-102
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85016-6262
Practice Address - Country:US
Practice Address - Phone:602-955-6632
Practice Address - Fax:602-381-1341
Is Sole Proprietor?:No
Enumeration Date:2011-03-17
Last Update Date:2018-05-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ48026207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine