Healthcare Provider Details

I. General information

NPI: 1699562017
Provider Name (Legal Business Name): ANUDEETA GAUTAM MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/21/2025
Last Update Date: 06/19/2025
Certification Date: 06/19/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 MICHIGAN ST NE STE A601
GRAND RAPIDS MI
49503-2560
US

IV. Provider business mailing address

100 MICHIGAN ST NE STE A601
GRAND RAPIDS MI
49503-2560
US

V. Phone/Fax

Practice location:
  • Phone: 616-391-3777
  • Fax: 616-391-3755
Mailing address:
  • Phone: 616-391-3777
  • Fax: 616-391-3755

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2085R0001X
TaxonomyRadiation Oncology Physician
License Number4351055081
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: