Healthcare Provider Details

I. General information

NPI: 1548203540
Provider Name (Legal Business Name): ANTHONY R. GAUTHIER M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

Provider Other Name: ANTHONY R. GAUTHIER JR. MD

II. Dates (important events)

Enumeration Date: 06/14/2006
Last Update Date: 12/23/2024
Certification Date: 12/23/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1808 CHARLTON CT
GOSHEN IN
46526-6463
US

IV. Provider business mailing address

1808 CHARLTON CT
GOSHEN IN
46526-6463
US

V. Phone/Fax

Practice location:
  • Phone: 574-533-8420
  • Fax: 574-534-5822
Mailing address:
  • Phone: 574-533-8420
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208800000X
TaxonomyUrology Physician
License Number4301079102
License Number StateMI
# 2
Primary TaxonomyY
Taxonomy Code208800000X
TaxonomyUrology Physician
License Number01077751A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: