Healthcare Provider Details

I. General information

NPI: 1295816270
Provider Name (Legal Business Name): RAKSHA R GUPTA MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/18/2006
Last Update Date: 09/29/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

920 MAIN ST
HACKENSACK NJ
07601
US

IV. Provider business mailing address

920 MAIN ST
HACKENSACK NJ
07601
US

V. Phone/Fax

Practice location:
  • Phone: 201-488-2200
  • Fax: 201-488-0211
Mailing address:
  • Phone: 201-488-2200
  • Fax: 201-488-0211

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberMA55012
License Number StateNJ

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: