Healthcare Provider Details

I. General information

NPI: 1447202163
Provider Name (Legal Business Name): RISHI GUPTA MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/17/2006
Last Update Date: 02/26/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

61 WHITCHER ST NE SUITE 3110
MARIETTA GA
30060-1176
US

IV. Provider business mailing address

61 WHITCHER ST NE SUITE 3110
MARIETTA GA
30060-1176
US

V. Phone/Fax

Practice location:
  • Phone: 770-422-2326
  • Fax: 770-422-7797
Mailing address:
  • Phone: 770-422-2326
  • Fax: 770-422-7797

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2084V0102X
TaxonomyVascular Neurology Physician
License Number064947
License Number StateGA
# 2
Primary TaxonomyY
Taxonomy Code207T00000X
TaxonomyNeurological Surgery Physician
License Number064947
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: