Healthcare Provider Details

I. General information

NPI: 1275755621
Provider Name (Legal Business Name): GAUTAM PRASAD M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/03/2007
Last Update Date: 05/21/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6380 CLARK AVE
DUBLIN CA
94568-3036
US

IV. Provider business mailing address

6380 CLARK AVE
DUBLIN CA
94568-3036
US

V. Phone/Fax

Practice location:
  • Phone: 925-875-1677
  • Fax: 925-875-0826
Mailing address:
  • Phone: 925-875-1677
  • Fax: 925-875-0826

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2085R0001X
TaxonomyRadiation Oncology Physician
License NumberA103317
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: