Basic Information
| Provider Information | |||||||||
| NPI: | 1871714204 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | WETZEL GUPTA | ||||||||
| FirstName: | RAEGAN | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 347 HELIOS AVE | ||||||||
| Address2: | |||||||||
| City: | METAIRIE | ||||||||
| State: | LA | ||||||||
| PostalCode: | 700053756 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3377394153 | ||||||||
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| Practice Location | |||||||||
| Address1: | 200 HENRY CLAY AVE | ||||||||
| Address2: | |||||||||
| City: | NEW ORLEANS | ||||||||
| State: | LA | ||||||||
| PostalCode: | 701185720 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5048999511 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 05/02/2007 | ||||||||
| LastUpdateDate: | 08/11/2011 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2080N0001X | 202693 | LA | Y | Allopathic & Osteopathic Physicians | Pediatrics | Neonatal-Perinatal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 1982342 | 05 | LA | MEDICAID |