Provider Demographics
NPI:1952656399
Name:RAJPUT, GAURAV KUMAR (DO)
Entity Type:Individual
Prefix:DR
First Name:GAURAV
Middle Name:KUMAR
Last Name:RAJPUT
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1288 WELLBROOK CIR NE STE A
Mailing Address - Street 2:
Mailing Address - City:CONYERS
Mailing Address - State:GA
Mailing Address - Zip Code:30012-8032
Mailing Address - Country:US
Mailing Address - Phone:783-696-9346
Mailing Address - Fax:770-679-5556
Practice Address - Street 1:2675 N DECATUR RD STE 401
Practice Address - Street 2:
Practice Address - City:DECATUR
Practice Address - State:GA
Practice Address - Zip Code:30033-6133
Practice Address - Country:US
Practice Address - Phone:678-369-6934
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-07-23
Last Update Date:2018-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY265837-1208100000X
GA0696982081P2900X, 208VP0000X, 208VP0014X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208VP0014XAllopathic & Osteopathic PhysiciansPain MedicineInterventional Pain Medicine
No208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
No2081P2900XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationPain Medicine
No208VP0000XAllopathic & Osteopathic PhysiciansPain MedicinePain Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA003137509AMedicaid
GA003137509BMedicaid
GA003137509CMedicaid
GA003137509DMedicaid
KY7100314030Medicaid
GA003137509FMedicaid
GA003137509AMedicaid
GA003137509CMedicaid