Healthcare Provider Details

I. General information

NPI: 1629118740
Provider Name (Legal Business Name): RAGHAV GUPTA MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/07/2007
Last Update Date: 12/22/2022
Certification Date: 12/22/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

836 PRUDENTIAL DR STE 1700
JACKSONVILLE FL
32207-8344
US

IV. Provider business mailing address

PO BOX 746652
ATLANTA GA
30374-6652
US

V. Phone/Fax

Practice location:
  • Phone: 904-398-0125
  • Fax: 904-398-1832
Mailing address:
  • Phone: 904-720-0599
  • Fax: 904-376-4036

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License NumberME158258
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code207RI0011X
TaxonomyInterventional Cardiology Physician
License Number25029
License Number StateOK
# 3
Primary TaxonomyY
Taxonomy Code207RI0011X
TaxonomyInterventional Cardiology Physician
License NumberME158258
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: