Healthcare Provider Details

I. General information

NPI: 1831944875
Provider Name (Legal Business Name): DIPENDRA GAUTAM PHYSICAL THERAPY INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/23/2024
Last Update Date: 06/08/2025
Certification Date: 06/08/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

502 TRAVERSE DR S
MADERA CA
93636-9038
US

IV. Provider business mailing address

502 TRAVERSE DR S
MADERA CA
93636-9038
US

V. Phone/Fax

Practice location:
  • Phone: 559-396-4681
  • Fax:
Mailing address:
  • Phone: 595-396-4681
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number
License Number State

VIII. Authorized Official

Name: DIPENDRA GAUTAM
Title or Position: PHYSICAL THERAPIST
Credential: DPT
Phone: 703-626-9334