Provider Demographics
NPI:1790751949
Name:GUPTA, RAVI (MD)
Entity Type:Individual
Prefix:
First Name:RAVI
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 1:2075 W PECOS RD STE 2
Mailing Address - Street 2:
Mailing Address - City:CHANDLER
Mailing Address - State:AZ
Mailing Address - Zip Code:85224-5723
Mailing Address - Country:US
Mailing Address - Phone:480-219-6840
Mailing Address - Fax:480-219-6841
Practice Address - Street 1:2075 W PECOS RD, SUITE#2
Practice Address - Street 2:
Practice Address - City:CHANDLER
Practice Address - State:AZ
Practice Address - Zip Code:85224-5693
Practice Address - Country:US
Practice Address - Phone:480-289-4550
Practice Address - Fax:602-765-9513
Is Sole Proprietor?:No
Enumeration Date:2006-02-27
Last Update Date:2011-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ33007207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ866965Medicaid
AZP00271516OtherRAIL ROAD MEDICARE ID
AZI10152Medicare UPIN
AZZ127208Medicare PIN
Z105822Medicare PIN