Healthcare Provider Details

I. General information

NPI: 1003445966
Provider Name (Legal Business Name): ASMITA GAUTAM MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/03/2020
Last Update Date: 07/29/2025
Certification Date: 07/15/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1000 EAST GENESEE ST. 5TH FLOOR
SYRACUSE NY
13210
US

IV. Provider business mailing address

1000 EAST GENESEE ST. 5TH FLOOR
SYRACUSE NY
13210
US

V. Phone/Fax

Practice location:
  • Phone: 315-464-2929
  • Fax: 315-464-2930
Mailing address:
  • Phone: 315-464-2929
  • Fax: 315-464-2930

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number337434-01
License Number StateNY
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number337434
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: