Provider Demographics
NPI:1447314737
Name:JHA, GAUTAM (MD)
Entity type:Individual
Prefix:MR
First Name:GAUTAM
Middle Name:
Last Name:JHA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1325 W. WHITTAKER
Mailing Address - Street 2:SUITE D
Mailing Address - City:SALEM
Mailing Address - State:IL
Mailing Address - Zip Code:62881
Mailing Address - Country:US
Mailing Address - Phone:618-740-0300
Mailing Address - Fax:618-740-0301
Practice Address - Street 1:1325 W. WHITTAKER
Practice Address - Street 2:SUITE D
Practice Address - City:SALEM
Practice Address - State:IL
Practice Address - Zip Code:62881
Practice Address - Country:US
Practice Address - Phone:618-740-0300
Practice Address - Fax:618-740-0301
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-20
Last Update Date:2024-10-11
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
IL036096423207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036096423Medicaid
ILG86213Medicare UPIN
IL529310Medicare UPIN