Provider Demographics
NPI:1821988908
Name:GAUTAM, KESHAV MANI
Entity type:Individual
Prefix:
First Name:KESHAV
Middle Name:MANI
Last Name:GAUTAM
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:50 PRESIDENTIAL PLZ APT 307
Mailing Address - Street 2:
Mailing Address - City:SYRACUSE
Mailing Address - State:NY
Mailing Address - Zip Code:13202-2267
Mailing Address - Country:US
Mailing Address - Phone:315-374-5052
Mailing Address - Fax:
Practice Address - Street 1:750 E ADAMS ST
Practice Address - Street 2:
Practice Address - City:SYRACUSE
Practice Address - State:NY
Practice Address - Zip Code:13210-2306
Practice Address - Country:US
Practice Address - Phone:315-464-5540
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-07-08
Last Update Date:2025-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program