Provider Demographics
NPI:1528293354
Name:VISVESWARAN, GAUTAM K (MD)
Entity type:Individual
Prefix:
First Name:GAUTAM
Middle Name:K
Last Name:VISVESWARAN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:GAUTAM
Other - Middle Name:K
Other - Last Name:VISWESWARAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:201 LYONS AVE
Mailing Address - Street 2:DIVISION OF CARDIOVASCULAR MEDICINE
Mailing Address - City:NEWARK
Mailing Address - State:NJ
Mailing Address - Zip Code:07112-2027
Mailing Address - Country:US
Mailing Address - Phone:932-926-7340
Mailing Address - Fax:973-926-6526
Practice Address - Street 1:201 LYONS AVE
Practice Address - Street 2:DIVISION OF CARDIOVASCULAR MEDICINE
Practice Address - City:NEWARK
Practice Address - State:NJ
Practice Address - Zip Code:07112-2027
Practice Address - Country:US
Practice Address - Phone:932-926-7852
Practice Address - Fax:973-282-0839
Is Sole Proprietor?:Yes
Enumeration Date:2009-05-22
Last Update Date:2023-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA09277200207R00000X, 207RI0011X
PAMD446413207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RI0011XAllopathic & Osteopathic PhysiciansInternal MedicineInterventional Cardiology
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine