Provider Demographics
NPI:1124103403
Name:GUPTA, RAJ K (MD)
Entity type:Individual
Prefix:DR
First Name:RAJ
Middle Name:K
Last Name:GUPTA
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:117 SOUTH MAIN STREET
Mailing Address - Street 2:REIBOLD BUILDING
Mailing Address - City:DAYTON
Mailing Address - State:OH
Mailing Address - Zip Code:45422
Mailing Address - Country:US
Mailing Address - Phone:937-225-4954
Mailing Address - Fax:937-496-3071
Practice Address - Street 1:31 N LOCUST ST
Practice Address - Street 2:
Practice Address - City:WEST CARROLLTON
Practice Address - State:OH
Practice Address - Zip Code:45449-1407
Practice Address - Country:US
Practice Address - Phone:937-898-7750
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35100034208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0317802Medicaid