Healthcare Provider Details

I. General information

NPI: 1316207624
Provider Name (Legal Business Name): GAUTHAM KANAGARAJ M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/21/2012
Last Update Date: 03/21/2025
Certification Date: 03/21/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

200 S ENOTA DR NE STE 480
GAINESVILLE GA
30501-3473
US

IV. Provider business mailing address

PO BOX 1060
OAKWOOD GA
30566-0018
US

V. Phone/Fax

Practice location:
  • Phone: 770-219-0950
  • Fax: 770-534-8025
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License NumberMD-18039
License Number StateHI
# 2
Primary TaxonomyN
Taxonomy Code207RC0001X
TaxonomyClinical Cardiac Electrophysiology Physician
License NumberMD-18039
License Number StateHI
# 3
Primary TaxonomyN
Taxonomy Code207RC0001X
TaxonomyClinical Cardiac Electrophysiology Physician
License NumberME16789
License Number StateFL
# 4
Primary TaxonomyY
Taxonomy Code207RC0001X
TaxonomyClinical Cardiac Electrophysiology Physician
License Number103145
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: