Healthcare Provider Details

I. General information

NPI: 1437445947
Provider Name (Legal Business Name): GAURAV NIGAM MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/22/2011
Last Update Date: 02/09/2024
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

911 STACY BURK DRIVE
FLORA IL
62839
US

IV. Provider business mailing address

1605 E PLAZA DR STE 103
TALLAHASSEE FL
32308-5327
US

V. Phone/Fax

Practice location:
  • Phone: 618-662-2131
  • Fax: 618-662-1473
Mailing address:
  • Phone: 850-878-7271
  • Fax: 850-878-1509

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberMD2018-0881
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: