Provider Demographics
NPI:1831172725
Name:GAUTAM, MANJUSHREE (MD)
Entity type:Individual
Prefix:DR
First Name:MANJUSHREE
Middle Name:
Last Name:GAUTAM
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1250 8TH AVE
Mailing Address - Street 2:SUITE 515
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76104-4124
Mailing Address - Country:US
Mailing Address - Phone:817-922-4675
Mailing Address - Fax:817-922-4645
Practice Address - Street 1:1250 8TH AVE
Practice Address - Street 2:SUITE 515
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76104-4124
Practice Address - Country:US
Practice Address - Phone:817-922-4675
Practice Address - Fax:817-922-4645
Is Sole Proprietor?:No
Enumeration Date:2005-11-23
Last Update Date:2015-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ33778207RI0008X
TXN6309207RG0100X, 207RT0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
No207RI0008XAllopathic & Osteopathic PhysiciansInternal MedicineHepatology
No207RT0003XAllopathic & Osteopathic PhysiciansInternal MedicineTransplant Hepatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX8BN847OtherBCBSTX
TX217199301Medicaid
AZ935554Medicaid
AZ86080015085259D008OtherTRIWEST
AZP00278312OtherRAILROAD MEDICARE
AZ86080015085259D008OtherTRIWEST
TX8BN847OtherBCBSTX
AZ935554Medicaid
TXTXB112127Medicare PIN
TX217199301Medicaid