Healthcare Provider Details

I. General information

NPI: 1427129279
Provider Name (Legal Business Name): MICHAEL DAVID GAUTREAUX PH.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/13/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

145 KIMEL PARK DR SUITE 250
WINSTON SALEM NC
27103-6984
US

IV. Provider business mailing address

145 KIMEL PARK DR SUITE 250
WINSTON SALEM NC
27103-6984
US

V. Phone/Fax

Practice location:
  • Phone: 336-716-4456
  • Fax: 336-774-7665
Mailing address:
  • Phone: 336-716-4456
  • Fax: 336-774-7665

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code170100000X
TaxonomyPh.D. Medical Genetics
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: