Provider Demographics
NPI:1548220585
Name:GUPTA, PRATIBHA N (MD)
Entity Type:Individual
Prefix:
First Name:PRATIBHA
Middle Name:N
Last Name:GUPTA
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:PRATIBHA
Other - Middle Name:S
Other - Last Name:RAO
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:PO BOX 44008
Mailing Address - Street 2:UFJP RADIOLOGY
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32231-4008
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:655 W 8TH ST
Practice Address - Street 2:UFJP RADIOLOGY
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32209-6511
Practice Address - Country:US
Practice Address - Phone:904-244-7244
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-03-24
Last Update Date:2009-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY1407232085R0202X
FLME1026482085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00976494Medicaid
FL000572100Medicaid
GA821975428AMedicaid
GA821975428AMedicaid
NY00976494Medicaid
NY0232AGMedicare ID - Type Unspecified
FLP00696455Medicare PIN