Healthcare Provider Details

I. General information

NPI: 1396997649
Provider Name (Legal Business Name): GAUTAM MUKUND PHADKE M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/17/2008
Last Update Date: 04/02/2025
Certification Date: 04/02/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1640 CAMPUS PARK DR STE C
MONROE NC
28112-5284
US

IV. Provider business mailing address

3158 FREEDOM DR STE 3102
CHARLOTTE NC
28208-0014
US

V. Phone/Fax

Practice location:
  • Phone: 704-226-0366
  • Fax: 704-226-9535
Mailing address:
  • Phone: 704-971-7099
  • Fax: 704-971-0035

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RN0300X
TaxonomyNephrology Physician
License Number2019-01383
License Number StateNC
# 2
Primary TaxonomyN
Taxonomy Code207RN0300X
TaxonomyNephrology Physician
License Number11322
License Number StateND
# 3
Primary TaxonomyN
Taxonomy Code207RN0300X
TaxonomyNephrology Physician
License Number2009006929
License Number StateMO
# 4
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License NumberRL10218
License Number StateND

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: