Provider Demographics
NPI:1629026067
Name:GUPTA, AJAY K (MD)
Entity Type:Individual
Prefix:DR
First Name:AJAY
Middle Name:K
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 1:6210 E US HWY 290
Mailing Address - Street 2:STE. 420 - CREDENTIALING
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78759-5785
Mailing Address - Country:US
Mailing Address - Phone:512-338-3826
Mailing Address - Fax:512-406-6216
Practice Address - Street 1:4515 SETON CENTER PKWY STE 220
Practice Address - Street 2:
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78759
Practice Address - Country:US
Practice Address - Phone:512-338-8388
Practice Address - Fax:512-406-6274
Is Sole Proprietor?:No
Enumeration Date:2006-05-05
Last Update Date:2019-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXJ8562207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX124005307Medicaid
TX124005308Medicaid
TX82T248OtherBCBSTX PROVIDER NUMB
TX82T248OtherBCBSTX PROVIDER NUMB
TXBG4632279OtherDEA NUMBER
TX742642860OtherTIN
TX45D0505324OtherCLIA
TX82T248Medicare ID - Type UnspecifiedINDIVIDUAL PROVIDER NUMB
TX00J40TMedicare ID - Type UnspecifiedPRACTICE PROVIDER NUMB
TX82T248OtherBCBSTX PROVIDER NUMB
TXG20633Medicare UPIN