Individual
DR. MANJUSHREE GAUTAM
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Credential
M.D.
Contact information
Practice address
1250 8TH AVE, SUITE 515, FORT WORTH, TX 76104-4124
(817) 922-4675
(817) 922-4645
Mailing address
1250 8TH AVE, SUITE 515, FORT WORTH, TX 76104-4124
(817) 922-4675
(817) 922-4645
Taxonomy
Speciality
Code
Description
License number
State
207RG0100X
Gastroenterology Physician
Primary
N6309
TX
207RI0008X
Hepatology Physician
33778
AZ
207RT0003X
Transplant Hepatology Physician
N6309
TX
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
217199301
—
TX
01
—
86080015085259D008
TRIWEST
AZ
01
—
8BN847
BCBSTX
TX
05
—
935554
—
AZ
01
—
P00278312
RAILROAD MEDICARE
AZ
Enumeration date
11/23/2005
Last updated
07/21/2015
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