Basic Information
| Provider Information | |||||||||
| NPI: | 1629026067 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | GUPTA | ||||||||
| FirstName: | AJAY | ||||||||
| MiddleName: | K | ||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 6210 E US HWY 290 | ||||||||
| Address2: | STE. 420 - CREDENTIALING | ||||||||
| City: | AUSTIN | ||||||||
| State: | TX | ||||||||
| PostalCode: | 787595785 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5123383826 | ||||||||
| FaxNumber: | 5124066216 | ||||||||
| Practice Location | |||||||||
| Address1: | 4515 SETON CENTER PKWY STE 220 | ||||||||
| Address2: | |||||||||
| City: | AUSTIN | ||||||||
| State: | TX | ||||||||
| PostalCode: | 78759 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5123388388 | ||||||||
| FaxNumber: | 5124066274 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/05/2006 | ||||||||
| LastUpdateDate: | 05/08/2019 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | J8562 | TX | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 124005307 | 05 | TX | MEDICAID | 124005308 | 05 | TX | MEDICAID | 82T248 | 01 | TX | BCBSTX PROVIDER NUMB | OTHER |