Provider Demographics
NPI:1780001404
Name:GAUTAM, SARITA
Entity Type:Individual
Prefix:
First Name:SARITA
Middle Name:
Last Name:GAUTAM
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1087 DENNISON AVE
Mailing Address - Street 2:STE 7
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43201-3201
Mailing Address - Country:US
Mailing Address - Phone:614-459-2906
Mailing Address - Fax:614-459-2932
Practice Address - Street 1:5100 W BROAD ST
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43228-1607
Practice Address - Country:US
Practice Address - Phone:614-544-1000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-03-19
Last Update Date:2018-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH34.013295207RP1001X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary Disease
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program