Provider Demographics
NPI:1356760433
Name:GAUTAM, KESHAP
Entity type:Individual
Prefix:
First Name:KESHAP
Middle Name:
Last Name:GAUTAM
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 1:45 MERIDEN AVE
Mailing Address - Street 2:
Mailing Address - City:SOUTHINGTON
Mailing Address - State:CT
Mailing Address - Zip Code:06489-3214
Mailing Address - Country:US
Mailing Address - Phone:949-371-4733
Mailing Address - Fax:
Practice Address - Street 1:45 MERIDEN AVE
Practice Address - Street 2:
Practice Address - City:SOUTHINGTON
Practice Address - State:CT
Practice Address - Zip Code:06489-3214
Practice Address - Country:US
Practice Address - Phone:860-453-4170
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-04-16
Last Update Date:2014-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT001413224Z00000X
CA2638224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant