Provider Demographics
NPI:1841797834
Name:GAUTAM, MOHAN
Entity Type:Individual
Prefix:
First Name:MOHAN
Middle Name:
Last Name:GAUTAM
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 1:26901 BEAUMONT BLVD # 3D
Mailing Address - Street 2:
Mailing Address - City:SOUTHFIELD
Mailing Address - State:MI
Mailing Address - Zip Code:48033-3849
Mailing Address - Country:US
Mailing Address - Phone:947-522-1952
Mailing Address - Fax:947-522-0307
Practice Address - Street 1:18001 ROTUNDA DR
Practice Address - Street 2:
Practice Address - City:DEARBORN
Practice Address - State:MI
Practice Address - Zip Code:48124-3984
Practice Address - Country:US
Practice Address - Phone:313-633-2300
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-04-07
Last Update Date:2023-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI51010265842084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry