MEDICARE: DR. MANJUSHREE GAUTAM M.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207RI0008X	Hepatology Physician	33778	AZ
2	207RG0100X	Gastroenterology Physician	N6309	TX
3	207RT0003X	Transplant Hepatology Physician	N6309	TX

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
5	P00278312	OTHER	AZ	RAILROAD MEDICARE

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	8BN847	OTHER	TX	BCBSTX
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
3	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
4	86080015085259D008	OTHER	AZ	TRIWEST

General Provider Information

NPI Number	:	1831172725
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. MANJUSHREE GAUTAM M.D.

Provider Business Mailing Address
First Line	:	1250 8TH AVE
Second Line	:	SUITE 515
City	:	FORT WORTH
State	:	TX
Zip	:	76104-4124
Country	:	US
Telephone Number	:	817-922-4675
Fax Number	:	817-922-4645

Provider Business Practice Location Address
First Line	:	1250 8TH AVE
Second Line	:	SUITE 515
City	:	FORT WORTH
State	:	TX
Zip	:	76104-4124
Country	:	US
Telephone Number	:	817-922-4675
Fax Number	:	817-922-4645

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	11/23/2005
Last Update Date	:	07/21/2015

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Directions to “ DR. MANJUSHREE GAUTAM M.D.” Practice Location

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