Provider Demographics
NPI:1023158482
Name:GAUTAM, ARCHANA (MD)
Entity type:Individual
Prefix:
First Name:ARCHANA
Middle Name:
Last Name:GAUTAM
Suffix:
Gender:F
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 1330
Mailing Address - Street 2:
Mailing Address - City:NORMAN
Mailing Address - State:OK
Mailing Address - Zip Code:73070-1330
Mailing Address - Country:US
Mailing Address - Phone:405-360-3089
Mailing Address - Fax:405-360-6765
Practice Address - Street 1:3500 HEALTHPLEX PKWY
Practice Address - Street 2:SUITE 200
Practice Address - City:NORMAN
Practice Address - State:OK
Practice Address - Zip Code:73072-9738
Practice Address - Country:US
Practice Address - Phone:405-515-2222
Practice Address - Fax:405-307-5617
Is Sole Proprietor?:No
Enumeration Date:2007-02-07
Last Update Date:2021-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK22150207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200113010BMedicaid
OKOKA102104Medicare PIN