Provider Demographics
NPI:1851562375
Name:GAUTHAM, SHANTA (MD)
Entity Type:Individual
Prefix:
First Name:SHANTA
Middle Name:
Last Name:GAUTHAM
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:SHANTA
Other - Middle Name:
Other - Last Name:SUBRAMANIAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:2401 DEMERS AVE
Mailing Address - Street 2:
Mailing Address - City:GRAND FORKS
Mailing Address - State:ND
Mailing Address - Zip Code:58201
Mailing Address - Country:US
Mailing Address - Phone:701-780-1891
Mailing Address - Fax:781-744-5358
Practice Address - Street 1:725 HAMLINE ST - ALTRU FAMILY MEDICINE RESIDENCY
Practice Address - Street 2:
Practice Address - City:GRAND FORKS
Practice Address - State:ND
Practice Address - Zip Code:58203
Practice Address - Country:US
Practice Address - Phone:701-780-6800
Practice Address - Fax:781-744-5358
Is Sole Proprietor?:No
Enumeration Date:2008-03-13
Last Update Date:2019-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND11672207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine