Basic Information
| Provider Information | |||||||||
| NPI: | 1285898312 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | GUPTA | ||||||||
| FirstName: | GAURAV | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 125 PATERSON ST | ||||||||
| Address2: | CAB 2102 | ||||||||
| City: | NEW BRUNSWICK | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 089011962 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7322357756 | ||||||||
| FaxNumber: | 7322357095 | ||||||||
| Practice Location | |||||||||
| Address1: | 125 PATERSON ST | ||||||||
| Address2: | CAB 2102 | ||||||||
| City: | NEW BRUNSWICK | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 089011962 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7322357756 | ||||||||
| FaxNumber: | 7322357095 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/17/2008 | ||||||||
| LastUpdateDate: | 03/16/2017 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207T00000X | 25MA08236700 | NJ | Y | Allopathic & Osteopathic Physicians | Neurological Surgery |
ID Information
| ID | Type | State | Issuer | Description | 0302864 | 05 | NJ | MEDICAID |