Healthcare Provider Details

I. General information

NPI: 1558777359
Provider Name (Legal Business Name): RAHUL GUPTA M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/01/2014
Last Update Date: 10/04/2022
Certification Date: 10/04/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

200 NORTH ST
GENEVA NY
14456-1561
US

IV. Provider business mailing address

100 KINGS HWY S
ROCHESTER NY
14617-5504
US

V. Phone/Fax

Practice location:
  • Phone: 315-787-5100
  • Fax: 315-787-5108
Mailing address:
  • Phone: 585-922-3144
  • Fax: 585-922-1399

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number288714
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: