Basic Information
| Provider Information | |||||||||
| NPI: | 1750649489 | ||||||||
| EntityType: | 1 | ||||||||
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| LastName: | DIXIT | ||||||||
| FirstName: | GAUTAM | ||||||||
| MiddleName: | DEEPAK | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1057 PAUL MAILLARD RD | ||||||||
| Address2: | |||||||||
| City: | LULING | ||||||||
| State: | LA | ||||||||
| PostalCode: | 700704349 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9857853655 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1514 JEFFERSON HWY | ||||||||
| Address2: | |||||||||
| City: | NEW ORLEANS | ||||||||
| State: | LA | ||||||||
| PostalCode: | 701212429 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5048424000 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 05/01/2012 | ||||||||
| LastUpdateDate: | 12/15/2015 | ||||||||
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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 | 207P00000X | MD.208227 | LA | Y | Allopathic & Osteopathic Physicians | Emergency Medicine |
ID Information
| ID | Type | State | Issuer | Description | 2402030 | 05 | LA | MEDICAID | 07529347 | 05 | MS | MEDICAID |