Provider Demographics
NPI:1891791703
Name:GAUTAM, RAVINDRA MOHARPAL (MD)
Entity Type:Individual
Prefix:
First Name:RAVINDRA
Middle Name:MOHARPAL
Last Name:GAUTAM
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 1519
Mailing Address - Street 2:
Mailing Address - City:BARSTOW
Mailing Address - State:CA
Mailing Address - Zip Code:92312-1519
Mailing Address - Country:US
Mailing Address - Phone:760-256-1004
Mailing Address - Fax:760-256-1055
Practice Address - Street 1:930 W MAIN ST
Practice Address - Street 2:
Practice Address - City:BARSTOW
Practice Address - State:CA
Practice Address - Zip Code:92311-2654
Practice Address - Country:US
Practice Address - Phone:760-256-1004
Practice Address - Fax:760-256-1055
Is Sole Proprietor?:No
Enumeration Date:2005-06-24
Last Update Date:2023-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA56418207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
G66439Medicare UPIN