Healthcare Provider Details

I. General information

NPI: 1780905190
Provider Name (Legal Business Name): RAHUL GUPTA M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/21/2010
Last Update Date: 01/25/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12 EXECUTIVE PARK DR NE STE 300 DEPARTMENT OF PSYCHIATRY
ATLANTA GA
30329-2206
US

IV. Provider business mailing address

139 RENAISSANCE PKWY NE
ATLANTA GA
30308-2324
US

V. Phone/Fax

Practice location:
  • Phone: 404-727-3886
  • Fax:
Mailing address:
  • Phone: 404-874-2224
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number072680
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code2084P0802X
TaxonomyAddiction Psychiatry Physician
License Number072680
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: