Provider Demographics
NPI:1457811796
Name:GUPTA, NEAL RAJ (MD)
Entity Type:Individual
Prefix:
First Name:NEAL
Middle Name:RAJ
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:PO BOX 742616
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30374-2616
Mailing Address - Country:US
Mailing Address - Phone:770-219-8430
Mailing Address - Fax:
Practice Address - Street 1:1515 RIVER PL STE 200
Practice Address - Street 2:
Practice Address - City:BRASELTON
Practice Address - State:GA
Practice Address - Zip Code:30517-5603
Practice Address - Country:US
Practice Address - Phone:770-848-6140
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-03-22
Last Update Date:2023-08-29
Deactivation Date:2023-05-27
Deactivation Code:
Reactivation Date:2023-06-19
Provider Licenses
StateLicense IDTaxonomies
GA95560207R00000X
GA10909390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program