Provider Demographics
NPI:1679732549
Name:BASKARAN, GAUTAM (MD)
Entity type:Individual
Prefix:
First Name:GAUTAM
Middle Name:
Last Name:BASKARAN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:705 E MARSHALL AVE STE 5001
Mailing Address - Street 2:
Mailing Address - City:LONGVIEW
Mailing Address - State:TX
Mailing Address - Zip Code:75601-5524
Mailing Address - Country:US
Mailing Address - Phone:903-315-4551
Mailing Address - Fax:903-315-3415
Practice Address - Street 1:705 E MARSHALL AVE STE 5001
Practice Address - Street 2:
Practice Address - City:LONGVIEW
Practice Address - State:TX
Practice Address - Zip Code:75601-5524
Practice Address - Country:US
Practice Address - Phone:903-315-4551
Practice Address - Fax:903-315-3415
Is Sole Proprietor?:No
Enumeration Date:2008-06-05
Last Update Date:2024-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2011014212207RP1001X
390200000X
TXQ0003207RP1001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary Disease
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXP02599916OtherMCRR
TX335691703Medicaid