Healthcare Provider Details

I. General information

NPI: 1780001404
Provider Name (Legal Business Name): SARITA GAUTAM
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/19/2014
Last Update Date: 09/11/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5100 W BROAD ST
COLUMBUS OH
43228-1607
US

IV. Provider business mailing address

1087 DENNISON AVE STE 7
COLUMBUS OH
43201-3201
US

V. Phone/Fax

Practice location:
  • Phone: 614-544-1000
  • Fax:
Mailing address:
  • Phone: 614-459-2906
  • Fax: 614-459-2932

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RP1001X
TaxonomyPulmonary Disease Physician
License Number34.013295
License Number StateOH
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: