Provider Demographics
NPI:1710639596
Name:JOSHI, GAUTAM
Entity Type:Individual
Prefix:
First Name:GAUTAM
Middle Name:
Last Name:JOSHI
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:827 N HAIRSTON RD STE D
Mailing Address - Street 2:
Mailing Address - City:STONE MOUNTAIN
Mailing Address - State:GA
Mailing Address - Zip Code:30083-3441
Mailing Address - Country:US
Mailing Address - Phone:770-755-5904
Mailing Address - Fax:770-755-5971
Practice Address - Street 1:827 N HAIRSTON RD STE D
Practice Address - Street 2:
Practice Address - City:STONE MOUNTAIN
Practice Address - State:GA
Practice Address - Zip Code:30083-3441
Practice Address - Country:US
Practice Address - Phone:770-755-5904
Practice Address - Fax:770-755-5971
Is Sole Proprietor?:Yes
Enumeration Date:2022-01-22
Last Update Date:2022-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARPH022957183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist