Healthcare Provider Details

I. General information

NPI: 1114533619
Provider Name (Legal Business Name): NITESH GAUTAM MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/20/2020
Last Update Date: 06/05/2026
Certification Date: 06/05/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7388 TURFWAY RD
FLORENCE KY
41042-1381
US

IV. Provider business mailing address

3400 S BOWMAN RD APT 2007
LITTLE ROCK AR
72211-4647
US

V. Phone/Fax

Practice location:
  • Phone: 859-287-3045
  • Fax: 859-525-8806
Mailing address:
  • Phone: 501-703-3540
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License Number61765
License Number StateKY
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: