Provider Demographics
NPI:1912252032
Name:GEORGE, GAUTAM (MD)
Entity Type:Individual
Prefix:DR
First Name:GAUTAM
Middle Name:
Last Name:GEORGE
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 1:834 WALNUT ST 650
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19107-5109
Mailing Address - Country:US
Mailing Address - Phone:215-955-5161
Mailing Address - Fax:215-955-6003
Practice Address - Street 1:330 MOUNT AUBURN ST
Practice Address - Street 2:
Practice Address - City:CAMBRIDGE
Practice Address - State:MA
Practice Address - Zip Code:02138-5502
Practice Address - Country:US
Practice Address - Phone:617-499-5160
Practice Address - Fax:617-499-5593
Is Sole Proprietor?:No
Enumeration Date:2012-07-14
Last Update Date:2019-09-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD465143207R00000X, 207RC0200X, 207RP1001X
MA251828207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary Disease
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No207RC0200XAllopathic & Osteopathic PhysiciansInternal MedicineCritical Care Medicine