Healthcare Provider Details

I. General information

NPI: 1104801836
Provider Name (Legal Business Name): ROBIN S. GAUTAM MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/15/2005
Last Update Date: 07/14/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

667 EASTLAND AVE SE
WARREN OH
44484-4503
US

IV. Provider business mailing address

8166 MARKET ST SUITE D
YOUNGSTOWN OH
44512-6262
US

V. Phone/Fax

Practice location:
  • Phone: 330-841-4507
  • Fax: 330-841-4193
Mailing address:
  • Phone: 330-953-3242
  • Fax: 330-953-3243

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207ZC0500X
TaxonomyCytopathology Physician
License Number35070187S
License Number StateOH
# 2
Primary TaxonomyN
Taxonomy Code207ZP0102X
TaxonomyAnatomic Pathology & Clinical Pathology Physician
License Number35070187S
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: