Basic Information
| Provider Information | |||||||||
| NPI: | 1700185667 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | AGGARWAL | ||||||||
| FirstName: | GAUTAM | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4041 N CENTRAL AVE | ||||||||
| Address2: | BLDG C | ||||||||
| City: | PHOENIX | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 850123313 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6022795262 | ||||||||
| FaxNumber: | 6022795390 | ||||||||
| Practice Location | |||||||||
| Address1: | 4131 N 24TH ST | ||||||||
| Address2: | STE. B-102 | ||||||||
| City: | PHOENIX | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 850166262 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6029556632 | ||||||||
| FaxNumber: | 6023811341 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/17/2011 | ||||||||
| LastUpdateDate: | 05/29/2018 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 48026 | AZ | Y | Allopathic & Osteopathic Physicians | Family Medicine |
No ID Information.