Basic Information
| Provider Information | |||||||||
| NPI: | 1952555666 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | GUPTA | ||||||||
| FirstName: | PRATEEK | ||||||||
| MiddleName: | KUMAR | ||||||||
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| Credential: | MBBS | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 1000 | ||||||||
| Address2: | DEPT # 457 | ||||||||
| City: | MEMPHIS | ||||||||
| State: | TN | ||||||||
| PostalCode: | 381480001 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9012726010 | ||||||||
| FaxNumber: | 9012666468 | ||||||||
| Practice Location | |||||||||
| Address1: | 1325 EASTMORELAND AVE | ||||||||
| Address2: | SUITE 310 | ||||||||
| City: | MEMPHIS | ||||||||
| State: | TN | ||||||||
| PostalCode: | 381043519 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9012726010 | ||||||||
| FaxNumber: | 9012666468 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/07/2008 | ||||||||
| LastUpdateDate: | 03/13/2017 | ||||||||
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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 | 2086S0129X | 51677 | TN | Y | Allopathic & Osteopathic Physicians | Surgery | Vascular Surgery |
ID Information
| ID | Type | State | Issuer | Description | 01303031 | 05 | MS | MEDICAID | 208461001 | 05 | AR | MEDICAID | Q009116 | 05 | TN | MEDICAID | 6026580 | 01 | TN | BCBS | OTHER |