Provider Demographics
NPI:1326084146
Name:GUPTA, RAGHAV RAJ (MD)
Entity Type:Individual
Prefix:
First Name:RAGHAV
Middle Name:RAJ
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 1:1850 LAKEPOINTE DRIVE
Mailing Address - Street 2:SUITE 200
Mailing Address - City:LEWISVILLE
Mailing Address - State:TX
Mailing Address - Zip Code:75057-6443
Mailing Address - Country:US
Mailing Address - Phone:972-436-5040
Mailing Address - Fax:972-221-0249
Practice Address - Street 1:1850 LAKEPOINTE DRIVE
Practice Address - Street 2:SUITE 200
Practice Address - City:LEWISVILLE
Practice Address - State:TX
Practice Address - Zip Code:75057-6443
Practice Address - Country:US
Practice Address - Phone:972-436-5040
Practice Address - Fax:972-221-0249
Is Sole Proprietor?:No
Enumeration Date:2006-06-21
Last Update Date:2014-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXL2293207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX0073JFOtherBCBS
TX8G6860OtherBCBS
TX158173801Medicaid
TXH43154Medicare UPIN
TX8G6860OtherBCBS
TX8A4350Medicare PIN
TX0073JFOtherBCBS