Basic Information
| Provider Information | |||||||||
| NPI: | 1114658267 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | GAUTAM | ||||||||
| FirstName: | PRATIMA | ||||||||
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| Credential: | OD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 220 WHEELER ST | ||||||||
| Address2: | |||||||||
| City: | CLIFFSIDE PARK | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 070101114 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2012450700 | ||||||||
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| Practice Location | |||||||||
| Address1: | 940 BELMONT ST | ||||||||
| Address2: | |||||||||
| City: | BROCKTON | ||||||||
| State: | MA | ||||||||
| PostalCode: | 023015596 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5085834500 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 06/20/2022 | ||||||||
| LastUpdateDate: | 06/20/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 06/20/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 152W00000X | 00000000 | MA | Y | Eye and Vision Services Providers | Optometrist |
ID Information
| ID | Type | State | Issuer | Description | 24 | 05 | MA | MEDICAID |