Provider Demographics
NPI:1841914470
Name:GAUTAM, NEERAJ
Entity type:Individual
Prefix:
First Name:NEERAJ
Middle Name:
Last Name:GAUTAM
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3123 FOREST RD APT 201
Mailing Address - Street 2:
Mailing Address - City:LANSING
Mailing Address - State:MI
Mailing Address - Zip Code:48910-3850
Mailing Address - Country:US
Mailing Address - Phone:727-377-1959
Mailing Address - Fax:
Practice Address - Street 1:3123 FOREST RD APT 201
Practice Address - Street 2:
Practice Address - City:LANSING
Practice Address - State:MI
Practice Address - Zip Code:48910-3850
Practice Address - Country:US
Practice Address - Phone:727-377-1959
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-09-27
Last Update Date:2022-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5302040341183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist