Healthcare Provider Details

I. General information

NPI: 1700185667
Provider Name (Legal Business Name): GAUTAM AGGARWAL MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/17/2011
Last Update Date: 05/29/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4131 N 24TH ST STE. B-102
PHOENIX AZ
85016-6262
US

IV. Provider business mailing address

4041 N CENTRAL AVE BLDG C
PHOENIX AZ
85012-3313
US

V. Phone/Fax

Practice location:
  • Phone: 602-955-6632
  • Fax: 602-381-1341
Mailing address:
  • Phone: 602-279-5262
  • Fax: 602-279-5390

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number48026
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: