=====================================================
General NPI Number Information
=====================================================
NPI Number | 1831172725
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MANJUSHREE GAUTAM M.D.
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/23/2005
-----------------------------------------------------
Last Update Date | 07/21/2015
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1250 8TH AVE SUITE 515
-----------------------------------------------------
City | FORT WORTH
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 76104-4124
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 817-922-4675
-----------------------------------------------------
Fax | 817-922-4645
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1250 8TH AVE SUITE 515
-----------------------------------------------------
City | FORT WORTH
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 76104-4124
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 817-922-4675
-----------------------------------------------------
Fax | 817-922-4645
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207RI0008X
-----------------------------------------------------
Taxonomy Name | Hepatology Physician
-----------------------------------------------------
License Number | 33778
-----------------------------------------------------
License Number State | AZ
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 207RG0100X
-----------------------------------------------------
Taxonomy Name | Gastroenterology Physician
-----------------------------------------------------
License Number | N6309
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 207RT0003X
-----------------------------------------------------
Taxonomy Name | Transplant Hepatology Physician
-----------------------------------------------------
License Number | N6309
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------