Healthcare Provider Details

I. General information

NPI: 1205134731
Provider Name (Legal Business Name): MONA R GUPTA, DO INCORPORATED
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/08/2011
Last Update Date: 03/08/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8304 CREEDMOOR RD
RALEIGH NC
27613-1697
US

IV. Provider business mailing address

8304 CREEDMOOR RD
RALEIGH NC
27613-1697
US

V. Phone/Fax

Practice location:
  • Phone: 919-870-8409
  • Fax:
Mailing address:
  • Phone: 919-870-8409
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number200700366
License Number StateNC

VIII. Authorized Official

Name: DR. MONA RAJ GUPTA
Title or Position: PSYCHIATRIST/OWNER
Credential: DO
Phone: 919-870-8409