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General NPI Number Information
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NPI Number | 1891791703
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Entity Type | Individual
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Provider Name | RAVINDRA MOHARPAL GAUTAM M.D.
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Gender | Male
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Dates
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Enumeration Date | 06/24/2005
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Last Update Date | 05/09/2024
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Provider Practice Location Address
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Address Line | 930 W MAIN ST
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City | BARSTOW
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State | CA
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Zip | 92311-2654
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Country | US
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Telephone | 760-256-1004
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Fax | 760-256-1055
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Provider Business Mailing Address
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Address Line | PO BOX 35389
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City | BELFAST
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State | ME
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Zip | 04915-0631
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Country | US
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Telephone | 760-256-1004
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Fax | 760-256-1055
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207R00000X
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Taxonomy Name | Internal Medicine Physician
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License Number | A56418
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License Number State | CA
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