Healthcare Provider Details

I. General information

NPI: 1912982687
Provider Name (Legal Business Name): GAUTAM AGARWAL M.B.B.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/14/2005
Last Update Date: 09/08/2020
Certification Date: 09/08/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1120 15TH ST BA-4300
AUGUSTA GA
30912-0004
US

IV. Provider business mailing address

1499 WALTON WAY STE 1400
AUGUSTA GA
30901-2602
US

V. Phone/Fax

Practice location:
  • Phone: 706-721-3671
  • Fax:
Mailing address:
  • Phone: 706-828-8401
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2086S0129X
TaxonomyVascular Surgery Physician
License Number47831
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: