Healthcare Provider Details

I. General information

NPI: 1063417525
Provider Name (Legal Business Name): RAKESH GUPTA MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/20/2005
Last Update Date: 10/03/2024
Certification Date: 10/03/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7300 S RAEFORD RD
FAYETTEVILLE NC
28304-6162
US

IV. Provider business mailing address

2595 VIXEN ST
FAYETTEVILLE NC
28303-5002
US

V. Phone/Fax

Practice location:
  • Phone: 910-488-2120
  • Fax:
Mailing address:
  • Phone: 910-977-2995
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number39813
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: