Provider Demographics
NPI:1740203397
Name:GAUTHIER, JERRY W (MD)
Entity Type:Individual
Prefix:
First Name:JERRY
Middle Name:W
Last Name:GAUTHIER
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:PO BOX 421756
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77242-1756
Mailing Address - Country:US
Mailing Address - Phone:281-880-6991
Mailing Address - Fax:
Practice Address - Street 1:1140 BUSINESS CENTER DR
Practice Address - Street 2:SUITE 370
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77043-2737
Practice Address - Country:US
Practice Address - Phone:713-271-6881
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-25
Last Update Date:2009-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXH9945207ZP0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical Pathology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXP00358430OtherRAILROAD MEDICARE
TX8G7838Medicare PIN
TX8L1993Medicare PIN
TXG15769Medicare UPIN