Healthcare Provider Details

I. General information

NPI: 1598898421
Provider Name (Legal Business Name): GAUTAM KAUSHIK KHAKHAR M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/13/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3815 PUTNAM AVE W
BRONX NY
10463-2442
US

IV. Provider business mailing address

171 E 84TH ST APT 21J
NEW YORK NY
10028-2000
US

V. Phone/Fax

Practice location:
  • Phone: 718-549-7260
  • Fax:
Mailing address:
  • Phone: 917-208-6877
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2081S0010X
TaxonomySports Medicine (Physical Medicine & Rehabilitation) Physician
License Number218201
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: