Healthcare Provider Details

I. General information

NPI: 1437879624
Provider Name (Legal Business Name): DIPENDRA GAUTAM
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/30/2022
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
US

IV. Provider business mailing address

7942 N MAPLE AVE STE 102
FRESNO CA
93720-0293
US

V. Phone/Fax

Practice location:
  • Phone: 703-626-9334
  • Fax:
Mailing address:
  • Phone: 595-396-4681
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2251G0304X
TaxonomyGeriatric Physical Therapist
License NumberPT298252
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: