Provider Demographics
NPI:1699474163
Name:GAUTAM VANGIPURAM MD INC
Entity type:Organization
Organization Name:GAUTAM VANGIPURAM MD INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:
Authorized Official - First Name:GAUTAM
Authorized Official - Middle Name:
Authorized Official - Last Name:VANGIPURAM
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:815-342-1739
Mailing Address - Street 1:3565 COLONIAL AVE
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90066-2708
Mailing Address - Country:US
Mailing Address - Phone:815-342-1739
Mailing Address - Fax:
Practice Address - Street 1:555 PIER AVE STE D
Practice Address - Street 2:
Practice Address - City:HERMOSA BEACH
Practice Address - State:CA
Practice Address - Zip Code:90254-3801
Practice Address - Country:US
Practice Address - Phone:815-342-1739
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-02-23
Last Update Date:2023-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207WX0107XAllopathic & Osteopathic PhysiciansOphthalmologyRetina SpecialistGroup - Single Specialty