Healthcare Provider Details

I. General information

NPI: 1134388234
Provider Name (Legal Business Name): JAGAN DEWAN GUPTA M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/03/2008
Last Update Date: 12/17/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1111 MEDICAL CENTER BLVD SUITE N-108
MARRERO LA
70072-3151
US

IV. Provider business mailing address

2529 NASHVILLE AVE
NEW ORLEANS LA
70115-7045
US

V. Phone/Fax

Practice location:
  • Phone: 504-349-1461
  • Fax: 504-349-1461
Mailing address:
  • Phone: 504-813-3649
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2085N0700X
TaxonomyNeuroradiology Physician
License NumberMD.202042
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: