Provider Demographics
NPI:1629636659
Name:EDHAYAN, GAUTAM ELANGO (MD, MSE)
Entity type:Individual
Prefix:
First Name:GAUTAM
Middle Name:ELANGO
Last Name:EDHAYAN
Suffix:
Gender:M
Credentials:MD, MSE
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:301 UNIVERSITY BLVD
Mailing Address - Street 2:
Mailing Address - City:GALVESTON
Mailing Address - State:TX
Mailing Address - Zip Code:77555-0709
Mailing Address - Country:US
Mailing Address - Phone:409-747-2849
Mailing Address - Fax:409-772-7120
Practice Address - Street 1:301 UNIVERSITY BLVD
Practice Address - Street 2:
Practice Address - City:GALVESTON
Practice Address - State:TX
Practice Address - Zip Code:77555-6712
Practice Address - Country:US
Practice Address - Phone:409-747-2849
Practice Address - Fax:409-772-7120
Is Sole Proprietor?:Yes
Enumeration Date:2019-06-04
Last Update Date:2020-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXBP100702472085R0202X
MI4351044851208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic RadiologyGroup - Multi-Specialty
No208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Multi-Specialty