Healthcare Provider Details

I. General information

NPI: 1952303240
Provider Name (Legal Business Name): CHAKSHU GAUTAM M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/01/2005
Last Update Date: 10/23/2023
Certification Date: 10/23/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3149 AMBASSADOR CAFFERY PKWY
LAFAYETTE LA
70506-7209
US

IV. Provider business mailing address

3149 AMBASSADOR CAFFERY PKWY
LAFAYETTE LA
70506-7209
US

V. Phone/Fax

Practice location:
  • Phone: 337-288-5961
  • Fax: 337-706-3415
Mailing address:
  • Phone: 337-288-5961
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number15033R
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: