Healthcare Provider Details

I. General information

NPI: 1285704494
Provider Name (Legal Business Name): RAKESH KUMAR GUPTA MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/08/2006
Last Update Date: 07/23/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1501 WABASH ST STE 303
MICHIGAN CITY IN
46360
US

IV. Provider business mailing address

1501 WABASH ST SUITE 303
MICHIGAN CITY IN
46360-4360
US

V. Phone/Fax

Practice location:
  • Phone: 219-874-8711
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RG0100X
TaxonomyGastroenterology Physician
License Number01029292
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: