Provider Demographics
NPI:1972611911
Name:GAUTHAM, KANEKAL SURESH (MBBS, MD, DM, MS)
Entity type:Individual
Prefix:DR
First Name:KANEKAL
Middle Name:SURESH
Last Name:GAUTHAM
Suffix:
Gender:M
Credentials:MBBS, MD, DM, MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6410 FANNIN ST STE 470
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77030-3008
Mailing Address - Country:US
Mailing Address - Phone:713-500-5736
Mailing Address - Fax:713-500-0653
Practice Address - Street 1:6410 FANNIN ST STE 470
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77030-3008
Practice Address - Country:US
Practice Address - Phone:713-500-5736
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-29
Last Update Date:2025-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SCTL265862080N0001X
FLME1506262080N0001X
TXQ28552080N0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080N0001XAllopathic & Osteopathic PhysiciansPediatricsNeonatal-Perinatal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCQ09841Medicaid
FL110863200Medicaid
G90803Medicare UPIN