Provider Demographics
NPI:1619372182
Name:GAUTAM, SUDARSON (OTR/L)
Entity type:Individual
Prefix:MR
First Name:SUDARSON
Middle Name:
Last Name:GAUTAM
Suffix:
Gender:M
Credentials:OTR/L
Other - Prefix:MR
Other - First Name:SUDARSON
Other - Middle Name:
Other - Last Name:GAUTAM
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:OTR/L
Mailing Address - Street 1:446 OLD FARM RD
Mailing Address - Street 2:
Mailing Address - City:PALMYRA
Mailing Address - State:PA
Mailing Address - Zip Code:17078-8720
Mailing Address - Country:US
Mailing Address - Phone:717-813-0115
Mailing Address - Fax:
Practice Address - Street 1:446 OLD FARM RD APT 2
Practice Address - Street 2:
Practice Address - City:PALMYRA
Practice Address - State:PA
Practice Address - Zip Code:17078-8720
Practice Address - Country:US
Practice Address - Phone:717-813-0115
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-10-27
Last Update Date:2025-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOC016192225XP0019X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225XP0019XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPhysical Rehabilitation