Healthcare Provider Details

I. General information

NPI: 1629636659
Provider Name (Legal Business Name): GAUTAM ELANGO EDHAYAN MD, MSE
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/04/2019
Last Update Date: 04/29/2026
Certification Date: 04/29/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1600 SW ARCHER RD
GAINESVILLE FL
32610-0374
US

IV. Provider business mailing address

PO BOX 100374
GAINESVILLE FL
32610-0374
US

V. Phone/Fax

Practice location:
  • Phone: 352-265-0291
  • Fax: 352-265-0279
Mailing address:
  • Phone: 352-265-0291
  • Fax: 352-265-0279

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2085R0204X
TaxonomyVascular & Interventional Radiology Physician
License NumberME181294
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: