Provider Demographics
NPI:1316950504
Name:GAUTAM, HIND MIRZA (MD)
Entity type:Individual
Prefix:
First Name:HIND
Middle Name:MIRZA
Last Name:GAUTAM
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:HIND
Other - Middle Name:A
Other - Last Name:MIRZA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:PO BOX 735044
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60673-5044
Mailing Address - Country:US
Mailing Address - Phone:800-326-2250
Mailing Address - Fax:
Practice Address - Street 1:1881 CHICAGO ST
Practice Address - Street 2:
Practice Address - City:DE PERE
Practice Address - State:WI
Practice Address - Zip Code:54115-3770
Practice Address - Country:US
Practice Address - Phone:920-403-8000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-15
Last Update Date:2024-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI49944208VP0014X
WI49944-020207LP2900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207LP2900XAllopathic & Osteopathic PhysiciansAnesthesiologyPain Medicine
Yes208VP0014XAllopathic & Osteopathic PhysiciansPain MedicineInterventional Pain Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI34748200Medicaid
WII16040Medicare UPIN
WI34748200Medicaid