| Micky Gautam, D.o., P.a. | |
|
7808 Clodus Fields Dr Dallas TX 75251-2206 | |
| (214) 223-9235 | |
| (817) 730-9080 |
| Full Name | Micky Gautam, D.o., P.a. |
|---|---|
| Speciality | Psychiatry & Neurology |
| Location | 7808 Clodus Fields Dr, Dallas, Texas |
| Authorized Official Name and Position | Micky Keyurnath Gautam (OWNER/PRESIDENT) |
| Authorized Official Contact | 2142239235 |
| Accepts Medicare Insurance | Yes. This clinic participates in medicare program and accept medicare insurance. |
| Mailing Address | Practice Location Address |
|---|---|
| Micky Gautam, D.o., P.a. Po Box 561136 The Colony TX 75056-6136 Ph: (214) 223-9235 | Micky Gautam, D.o., P.a. 7808 Clodus Fields Dr Dallas TX 75251-2206 Ph: (214) 223-9235 |
| NPI Number | 1679719751 |
|---|---|
| Provider Enumeration Date | 12/19/2008 |
| Last Update Date | 07/25/2025 |
| Certification Date | 07/25/2025 |
| Medicare PECOS PAC ID | 4688821283 |
|---|---|
| Medicare Enrollment ID | O20120905000206 |
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 1679719751 | NPI | - | NPPES |
| L1861 | Other | TX | TX LICENSE |
| Taxonomy | Type | License (State) | Status |
|---|---|---|---|
| 2084P0800X | Psychiatry & Neurology - Psychiatry | L1861 (Texas) | Primary |
| Provider Name | Micky Gautam |
|---|---|
| Provider Type | Practitioner - Psychiatry |
| Provider Identifiers | NPI Number: 1518067602 PECOS PAC ID: 5496842643 Enrollment ID: I20071109000237 |
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