Basic Information
| Provider Information | |||||||||
| NPI: | 1790725240 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | GUPTA | ||||||||
| FirstName: | RAJAT | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 70 | ||||||||
| Address2: | |||||||||
| City: | LAKE FOREST | ||||||||
| State: | IL | ||||||||
| PostalCode: | 600450070 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 1324 N SHERIDAN RD | ||||||||
| Address2: | |||||||||
| City: | WAUKEGAN | ||||||||
| State: | IL | ||||||||
| PostalCode: | 600852161 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8473603000 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 06/06/2006 | ||||||||
| LastUpdateDate: | 05/27/2008 | ||||||||
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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 | 207L00000X | 036101774 | IL | Y | Allopathic & Osteopathic Physicians | Anesthesiology | 208VP0014X | 036101774 | IL | N | Allopathic & Osteopathic Physicians | Pain Medicine | Interventional Pain Medicine |
ID Information
| ID | Type | State | Issuer | Description | 036101774 | 05 | IL | MEDICAID |