Healthcare Provider Details

I. General information

NPI: 1114658267
Provider Name (Legal Business Name): PRATIMA GAUTAM OD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/20/2022
Last Update Date: 04/17/2025
Certification Date: 04/17/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

801 COOPER RD
OXNARD CA
93030-5445
US

IV. Provider business mailing address

1040 FLYNN RD
CAMARILLO CA
93012-5092
US

V. Phone/Fax

Practice location:
  • Phone: 805-330-8100
  • Fax: 805-240-7383
Mailing address:
  • Phone: 805-673-3930
  • Fax: 805-659-3217

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code152W00000X
TaxonomyOptometrist
License NumberTLG35439
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License NumberOPT35439
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: