Healthcare Provider Details

I. General information

NPI: 1831732809
Provider Name (Legal Business Name): RUPENDRA NATH GHATAK
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/23/2019
Last Update Date: 08/31/2026
Certification Date: 08/31/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6324 FAIRVIEW RD STE 400
CHARLOTTE NC
28210-4278
US

IV. Provider business mailing address

PO BOX 60447
CHARLOTTE NC
28260-0447
US

V. Phone/Fax

Practice location:
  • Phone: 980-302-6400
  • Fax:
Mailing address:
  • Phone: 336-277-5314
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number4351046259
License Number StateMI
# 2
Primary TaxonomyY
Taxonomy Code2084S0012X
TaxonomySleep Medicine (Psychiatry & Neurology) Physician
License Number2023-01031
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: