Provider Demographics
NPI:1245352970
Name:DUTTA, GAUTAM
Entity type:Individual
Prefix:
First Name:GAUTAM
Middle Name:
Last Name:DUTTA
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 1:127 N OAK AVE
Mailing Address - Street 2:SUITE D
Mailing Address - City:COOKEVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:38501-2435
Mailing Address - Country:US
Mailing Address - Phone:931-783-5857
Mailing Address - Fax:931-526-6760
Practice Address - Street 1:1 MEDICAL CENTER BLVD
Practice Address - Street 2:SUITE 103
Practice Address - City:COOKEVILLE
Practice Address - State:TN
Practice Address - Zip Code:38501-4294
Practice Address - Country:US
Practice Address - Phone:931-783-2770
Practice Address - Fax:931-525-1176
Is Sole Proprietor?:No
Enumeration Date:2007-04-04
Last Update Date:2021-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNMD45220208M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208M00000XAllopathic & Osteopathic PhysiciansHospitalist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN1516195Medicaid
TN103I114156Medicare PIN