Provider Demographics
NPI:1346487998
Name:RAVI GUPTA, MD, PLLC
Entity Type:Organization
Organization Name:RAVI GUPTA, MD, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:RAVI
Authorized Official - Middle Name:
Authorized Official - Last Name:GUPTA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:480-455-9616
Mailing Address - Street 1:2075 W PECOS RD
Mailing Address - Street 2:SUITE 2
Mailing Address - City:CHANDLER
Mailing Address - State:AZ
Mailing Address - Zip Code:85224-5722
Mailing Address - Country:US
Mailing Address - Phone:480-219-6840
Mailing Address - Fax:480-219-6841
Practice Address - Street 1:2075 W PECOS RD,
Practice Address - Street 2:STE 2
Practice Address - City:CHANDLER
Practice Address - State:AZ
Practice Address - Zip Code:85224-5693
Practice Address - Country:US
Practice Address - Phone:480-219-6840
Practice Address - Fax:480-219-6841
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-01-18
Last Update Date:2011-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ33007207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
1790751949OtherNPI PROVIDER
AZ866965Medicaid
AZZ127530Medicare PIN