Basic Information
| Provider Information | |||||||||
| NPI: | 1437117959 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | GUPTA | ||||||||
| FirstName: | RAJEEV | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | MR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 516 WEST ATEN ROAD | ||||||||
| Address2: | SUITE 2 | ||||||||
| City: | IMPERIAL | ||||||||
| State: | CA | ||||||||
| PostalCode: | 92251 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7603557730 | ||||||||
| FaxNumber: | 7603557731 | ||||||||
| Practice Location | |||||||||
| Address1: | 1550 N IMPERIAL AVE | ||||||||
| Address2: | SUITE 1 | ||||||||
| City: | EL CENTRO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 922436304 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7603521731 | ||||||||
| FaxNumber: | 7603371834 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/03/2006 | ||||||||
| LastUpdateDate: | 06/18/2008 | ||||||||
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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 | 207R00000X | A49489 | CA | Y | Allopathic & Osteopathic Physicians | Internal Medicine | 208000000X | A49489 | CA | N | Allopathic & Osteopathic Physicians | Pediatrics |
ID Information
| ID | Type | State | Issuer | Description | 110152471 | 01 | CA | RAILROAD PIN | OTHER | WA49489F | 01 | CA | MEDICARE PTAN | OTHER | ZZZ47481Z | 01 | CA | BLUE SHIELD OF CALIFORNIA | OTHER | GR0066310 | 05 | CA | MEDICAID | GR0066312 | 01 | CA | MEDI CAL GROUP NUMBER | OTHER | 00A494890 | 05 | CA | MEDICAID |