Provider Demographics
NPI:1275519399
Name:GUPTA, RAJ (MD)
Entity Type:Individual
Prefix:DR
First Name:RAJ
Middle Name:
Last Name:GUPTA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:222 E PEARSON ST
Mailing Address - Street 2:UNIT 2705
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60611-7347
Mailing Address - Country:US
Mailing Address - Phone:708-525-5008
Mailing Address - Fax:
Practice Address - Street 1:17850 KEDZIE AVE
Practice Address - Street 2:SUITE 3300
Practice Address - City:HAZEL CREST
Practice Address - State:IL
Practice Address - Zip Code:60429-2058
Practice Address - Country:US
Practice Address - Phone:708-799-6055
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-12-20
Last Update Date:2017-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036047397207RP1001X, 207RS0012X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary Disease
No207RS0012XAllopathic & Osteopathic PhysiciansInternal MedicineSleep Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036047397Medicaid
791291236OtherRAILROAD MEDICARE PROVIDER #
110103119OtherRAILROAD MEDICARE PROVIDER #
IL036047397Medicaid
661632Medicare PIN
D13366Medicare UPIN