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General NPI Number Information
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NPI Number | 1699474163
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Entity Type | Organization
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Legal Business Name | GAUTAM VANGIPURAM MD INC
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Dates
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Enumeration Date | 02/23/2023
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Last Update Date | 02/23/2023
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Provider Practice Location Address
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Address Line | 555 PIER AVE STE D
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City | HERMOSA BEACH
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State | CA
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Zip | 90254-3801
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Country | US
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Telephone | 815-342-1739
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Fax |
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Provider Business Mailing Address
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Address Line | 3565 COLONIAL AVE
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City | LOS ANGELES
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State | CA
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Zip | 90066-2708
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Country | US
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Telephone | 815-342-1739
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Fax |
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Authorized Official
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Title or Position | PHYSICIAN
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Name | GAUTAM VANGIPURAM
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Credential | MD
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Telephone | 815-342-1739
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207WX0107X
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Taxonomy Name | Retina Specialist (Ophthalmology) Physician
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License Number |
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License Number State |
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