Provider Demographics
NPI:1700636651
Name:GAUTAM, PRASHANSA
Entity Type:Individual
Prefix:
First Name:PRASHANSA
Middle Name:
Last Name:GAUTAM
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:22 COLLEGE DR
Mailing Address - Street 2:
Mailing Address - City:STONY BROOK
Mailing Address - State:NY
Mailing Address - Zip Code:11790-2724
Mailing Address - Country:US
Mailing Address - Phone:631-624-5914
Mailing Address - Fax:
Practice Address - Street 1:50 S HUNTINGTON AVE
Practice Address - Street 2:
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02130-4713
Practice Address - Country:US
Practice Address - Phone:617-232-9500
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-03-25
Last Update Date:2024-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental