Basic Information
| Provider Information | |||||||||
| NPI: | 1659934776 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | DHANARAJ | ||||||||
| FirstName: | GAUTAM | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 19 ECKLES DR | ||||||||
| Address2: | |||||||||
| City: | BRANCHBURG | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 088763941 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 327 BEACH 19TH ST | ||||||||
| Address2: | |||||||||
| City: | FAR ROCKAWAY | ||||||||
| State: | NY | ||||||||
| PostalCode: | 116914423 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7188697000 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 04/15/2019 | ||||||||
| LastUpdateDate: | 04/15/2019 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 390200000X | Y | Student, Health Care | Student in an Organized Health Care Education/Training Program |
No ID Information.