Provider Demographics
NPI:1669784450
Name:KALYATANDA, GAUTAM SUBBAIAH (MD)
Entity type:Individual
Prefix:DR
First Name:GAUTAM
Middle Name:SUBBAIAH
Last Name:KALYATANDA
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 1:1600, SW ARCHER ROAD
Mailing Address - Street 2:BOX 100277
Mailing Address - City:GAINESVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32608-0277
Mailing Address - Country:US
Mailing Address - Phone:352-294-5445
Mailing Address - Fax:
Practice Address - Street 1:1600, SW ARCHER ROAD
Practice Address - Street 2:BOX 100277
Practice Address - City:GAINESVILLE
Practice Address - State:FL
Practice Address - Zip Code:32608-0277
Practice Address - Country:US
Practice Address - Phone:352-294-5445
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-07-08
Last Update Date:2016-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA244719207R00000X
FLME128695207RI0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RI0200XAllopathic & Osteopathic PhysiciansInternal MedicineInfectious Disease
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL017893700Medicaid
FL017893700Medicaid