Healthcare Provider Details

I. General information

NPI: 1669784450
Provider Name (Legal Business Name): GAUTAM SUBBAIAH KALYATANDA M.D
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/08/2010
Last Update Date: 08/23/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1600, SW ARCHER ROAD BOX 100277
GAINESVILLE FL
32608-0277
US

IV. Provider business mailing address

1600, SW ARCHER ROAD BOX 100277
GAINESVILLE FL
32608-0277
US

V. Phone/Fax

Practice location:
  • Phone: 352-294-5445
  • Fax:
Mailing address:
  • Phone: 352-294-5445
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number244719
License Number StateMA
# 2
Primary TaxonomyY
Taxonomy Code207RI0200X
TaxonomyInfectious Disease Physician
License NumberME128695
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: