Healthcare Provider Details

I. General information

NPI: 1609062439
Provider Name (Legal Business Name): RENU GUPTA M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/14/2007
Last Update Date: 12/13/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

760 GOLF VIEW DRIVE SUITE #200
MEDFORD OR
97504-9685
US

IV. Provider business mailing address

760 GOLF VIEW DRIVE SUITE #200
MEDFORD OR
97504-9685
US

V. Phone/Fax

Practice location:
  • Phone: 541-618-4400
  • Fax: 541-618-4406
Mailing address:
  • Phone: 541-618-4400
  • Fax: 541-618-4406

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License NumberMD154260
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: