Provider Demographics
NPI:1124698519
Name:PATIL, GOUTHAM SHANKARGOUD (MD)
Entity type:Individual
Prefix:DR
First Name:GOUTHAM
Middle Name:SHANKARGOUD
Last Name:PATIL
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 1:44405 WOODWARD AVE # H-23
Mailing Address - Street 2:
Mailing Address - City:PONTIAC
Mailing Address - State:MI
Mailing Address - Zip Code:48341-5023
Mailing Address - Country:US
Mailing Address - Phone:646-633-3789
Mailing Address - Fax:
Practice Address - Street 1:44405 WOODWARD AVE # H-23
Practice Address - Street 2:
Practice Address - City:PONTIAC
Practice Address - State:MI
Practice Address - Zip Code:48341-5023
Practice Address - Country:US
Practice Address - Phone:646-633-3789
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-06-28
Last Update Date:2021-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5315225359207R00000X
MI4351048155207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine