Provider Demographics
NPI:1518179373
Name:KEDIA, GAUTAM (MD)
Entity type:Individual
Prefix:DR
First Name:GAUTAM
Middle Name:
Last Name:KEDIA
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 1:2487 S GILBERT RD
Mailing Address - Street 2:STE 106-486
Mailing Address - City:GILBERT
Mailing Address - State:AZ
Mailing Address - Zip Code:85295-8899
Mailing Address - Country:US
Mailing Address - Phone:480-699-5536
Mailing Address - Fax:480-699-9283
Practice Address - Street 1:3011 S LINDSAY RD
Practice Address - Street 2:SUITE 105
Practice Address - City:GILBERT
Practice Address - State:AZ
Practice Address - Zip Code:85295-4332
Practice Address - Country:US
Practice Address - Phone:480-699-5536
Practice Address - Fax:480-699-9283
Is Sole Proprietor?:No
Enumeration Date:2007-05-04
Last Update Date:2014-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ44342207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ872220Medicaid
AZZ164522Medicare PIN