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General NPI Number Information
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NPI Number | 1679719751
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Entity Type | Organization
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Legal Business Name | MICKY GAUTAM, D.O., P.A.
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Dates
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Enumeration Date | 12/19/2008
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Last Update Date | 07/25/2025
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Provider Practice Location Address
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Address Line | 7808 CLODUS FIELDS DR
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City | DALLAS
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State | TX
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Zip | 75251-2206
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Country | US
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Telephone | 214-223-9235
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Fax | 817-730-9080
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Provider Business Mailing Address
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Address Line | PO BOX 561136
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City | THE COLONY
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State | TX
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Zip | 75056-6136
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Country | US
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Telephone | 214-223-9235
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Fax | 817-730-9080
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Authorized Official
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Title or Position | OWNER/PRESIDENT
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Name | DR. MICKY KEYURNATH GAUTAM
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Credential | D.O.
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Telephone | 214-223-9235
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 2084P0800X
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Taxonomy Name | Psychiatry Physician
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License Number | L1861
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License Number State | TX
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