1417936261 NPI number — RAJEEV GUPTA M.D.

Table of content: RAJEEV GUPTA M.D. (NPI 1417936261)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1417936261 NPI number — RAJEEV GUPTA M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
GUPTA
Provider First Name:
RAJEEV
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
M.D.
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1417936261
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
04/02/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
489 AGNES ST
Provider Second Line Business Mailing Address:
100
Provider Business Mailing Address City Name:
BASTROP
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
78602-2156
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
512-321-9091
Provider Business Mailing Address Fax Number:
512-549-3005

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
489 AGNES ST
Provider Second Line Business Practice Location Address:
100
Provider Business Practice Location Address City Name:
BASTROP
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
78602-2156
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
512-321-9091
Provider Business Practice Location Address Fax Number:
512-549-3005
Provider Enumeration Date:
01/11/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207R00000X , with the licence number:  K0795 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 0071DM . This is a "BC/BS" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: 092494601 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".
  • Identifier: 135791506 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".
  • Identifier: 85180X . This is a "BC/BS" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: 10008423 . This is a "AMERIGROUP" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: DG3304 . This is a "RAILROAD MEDICARE" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".




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