Healthcare Provider Details

I. General information

NPI: 1588676407
Provider Name (Legal Business Name): GAUTAM SUKHABHAI BHAKTA MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/12/2006
Last Update Date: 06/24/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

205 S HALCYON RD
ARROYO GRANDE CA
93420-2602
US

IV. Provider business mailing address

205 S HALCYON RD
ARROYO GRANDE CA
93420-2602
US

V. Phone/Fax

Practice location:
  • Phone: 805-474-6110
  • Fax: 805-474-4020
Mailing address:
  • Phone: 805-474-6110
  • Fax: 805-474-4020

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberG79193
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code208M00000X
TaxonomyHospitalist Physician
License NumberG79193
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: