Healthcare Provider Details

I. General information

NPI: 1124103403
Provider Name (Legal Business Name): RAJ K GUPTA MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/26/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

31 N LOCUST ST
WEST CARROLLTON OH
45449-1407
US

IV. Provider business mailing address

117 SOUTH MAIN STREET REIBOLD BUILDING
DAYTON OH
45422
US

V. Phone/Fax

Practice location:
  • Phone: 937-898-7750
  • Fax:
Mailing address:
  • Phone: 937-225-4954
  • Fax: 937-496-3071

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number35100034
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: