Provider Demographics
NPI:1447538871
Name:GAUTAM, SMITA (MD)
Entity type:Individual
Prefix:
First Name:SMITA
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 1:8 S MICHIGAN AVE FL 10
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60603-3357
Mailing Address - Country:US
Mailing Address - Phone:312-609-5300
Mailing Address - Fax:
Practice Address - Street 1:8 S MICHIGAN AVE FL 10
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60603-3357
Practice Address - Country:US
Practice Address - Phone:312-609-5300
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-08-02
Last Update Date:2021-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL361355212084P0804X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Yes2084P0804XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyChild & Adolescent Psychiatry