Provider Demographics
NPI:1043283005
Name:GAUTAM, INDIRA (MD)
Entity type:Individual
Prefix:
First Name:INDIRA
Middle Name:
Last Name:GAUTAM
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:327 IBERIA ST
Mailing Address - Street 2:SUITE #3A
Mailing Address - City:YOUNGSVILLE
Mailing Address - State:LA
Mailing Address - Zip Code:70592-5738
Mailing Address - Country:US
Mailing Address - Phone:337-857-3512
Mailing Address - Fax:337-857-3513
Practice Address - Street 1:327 IBERIA ST
Practice Address - Street 2:SUITE #3A
Practice Address - City:YOUNGSVILLE
Practice Address - State:LA
Practice Address - Zip Code:70592-5738
Practice Address - Country:US
Practice Address - Phone:337-857-3512
Practice Address - Fax:337-857-3513
Is Sole Proprietor?:Yes
Enumeration Date:2006-02-09
Last Update Date:2014-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA15134R207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1191167Medicaid
LAH99599Medicare UPIN
LA4P857DC90Medicare PIN
8EA423Medicare ID - Type Unspecified