Provider Demographics
NPI:1689564072
Name:RAVINDRA GAUTAM, M.D., INC.
Entity type:Organization
Organization Name:RAVINDRA GAUTAM, M.D., INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:RAVINDRA
Authorized Official - Middle Name:MOHARPAL
Authorized Official - Last Name:GAUTAM
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:760-256-1004
Mailing Address - Street 1:930 W MAIN ST
Mailing Address - Street 2:
Mailing Address - City:BARSTOW
Mailing Address - State:CA
Mailing Address - Zip Code:92311-2654
Mailing Address - Country:US
Mailing Address - Phone:760-256-1004
Mailing Address - Fax:760-256-1055
Practice Address - Street 1:930 W MAIN ST
Practice Address - Street 2:
Practice Address - City:BARSTOW
Practice Address - State:CA
Practice Address - Zip Code:92311-2654
Practice Address - Country:US
Practice Address - Phone:760-256-1004
Practice Address - Fax:760-256-1055
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2025-07-07
Last Update Date:2025-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes171M00000XOther Service ProvidersCase Manager/Care CoordinatorGroup - Multi-Specialty