Provider Demographics
NPI:1295709418
Name:DAULAT, GAUTAM (DO)
Entity type:Individual
Prefix:DR
First Name:GAUTAM
Middle Name:
Last Name:DAULAT
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:39 DRIFTING SHADOW WAY
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89135-7879
Mailing Address - Country:US
Mailing Address - Phone:702-565-4917
Mailing Address - Fax:702-562-8680
Practice Address - Street 1:3416 N BUFFALO DR
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89129-7424
Practice Address - Country:US
Practice Address - Phone:702-565-4917
Practice Address - Fax:702-562-8680
Is Sole Proprietor?:No
Enumeration Date:2006-02-14
Last Update Date:2017-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NVDO 799207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NVP00883737OtherRAILROAD MEDICARE
NV1295709418Medicaid
NVBX397YMedicare PIN