Healthcare Provider Details

I. General information

NPI: 1295709418
Provider Name (Legal Business Name): GAUTAM DAULAT D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/14/2006
Last Update Date: 04/05/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3416 N BUFFALO DR
LAS VEGAS NV
89129-7424
US

IV. Provider business mailing address

39 DRIFTING SHADOW WAY
LAS VEGAS NV
89135-7879
US

V. Phone/Fax

Practice location:
  • Phone: 702-565-4917
  • Fax: 702-562-8680
Mailing address:
  • Phone: 702-565-4917
  • Fax: 702-562-8680

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberDO 799
License Number StateNV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: