Basic Information
| Provider Information | |||||||||
| NPI: | 1902891799 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | GAUTHIER | ||||||||
| FirstName: | J. | ||||||||
| MiddleName: | CLAUDE | ||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3495 PIEDMONT ROAD, NE | ||||||||
| Address2: | NINE PIEDMONT CENTER | ||||||||
| City: | ATLANTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 30305 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4043647070 | ||||||||
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| Practice Location | |||||||||
| Address1: | 2400 MT. ZION PARKWAY | ||||||||
| Address2: | KAISER PERMANENTE SOUTHWOOD MEDICAL OFFICE | ||||||||
| City: | JONESBORO | ||||||||
| State: | GA | ||||||||
| PostalCode: | 30236 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7706033614 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 09/17/2005 | ||||||||
| LastUpdateDate: | 02/24/2010 | ||||||||
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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 | 208000000X | 047595 | GA | Y | Allopathic & Osteopathic Physicians | Pediatrics |
ID Information
| ID | Type | State | Issuer | Description | 000833687B | 05 | GA | MEDICAID |