Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 208100000X | Physical Medicine & Rehabilitation Doctor | 2069440 | TX |
NPI | 1013552843 |
---|---|
Provider Name | Om Gautam |
First Address | Sherman, TX 75090-1704 |
Second Address | Sherman, TX 75090-1704 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 15/11/2019 |
Last Update Date | 15/11/2019 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
2069440 | TEXAS PT BOARD (01) | TX |