Provider Demographics
NPI:1437117959
Name:GUPTA, RAJEEV (MD)
Entity Type:Individual
Prefix:MR
First Name:RAJEEV
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 1:516 WEST ATEN ROAD
Mailing Address - Street 2:SUITE 2
Mailing Address - City:IMPERIAL
Mailing Address - State:CA
Mailing Address - Zip Code:92251
Mailing Address - Country:US
Mailing Address - Phone:760-355-7730
Mailing Address - Fax:760-355-7731
Practice Address - Street 1:1550 N IMPERIAL AVE
Practice Address - Street 2:SUITE 1
Practice Address - City:EL CENTRO
Practice Address - State:CA
Practice Address - Zip Code:92243-6304
Practice Address - Country:US
Practice Address - Phone:760-352-1731
Practice Address - Fax:760-337-1834
Is Sole Proprietor?:No
Enumeration Date:2006-05-03
Last Update Date:2008-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA49489207R00000X, 208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA110152471OtherRAILROAD PIN
CAWA49489FOtherMEDICARE PTAN
CAZZZ47481ZOtherBLUE SHIELD OF CALIFORNIA
CAGR0066310Medicaid
CAGR0066312OtherMEDI CAL GROUP NUMBER
CA00A494890Medicaid
CA110152471OtherRAILROAD PIN
CAZZZ47481ZOtherBLUE SHIELD OF CALIFORNIA
CAGR0066312OtherMEDI CAL GROUP NUMBER
CAW13536AMedicare PIN