Provider Demographics
NPI:1871714204
Name:WETZEL GUPTA, RAEGAN (MD)
Entity type:Individual
Prefix:
First Name:RAEGAN
Middle Name:
Last Name:WETZEL GUPTA
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:347 HELIOS AVE
Mailing Address - Street 2:
Mailing Address - City:METAIRIE
Mailing Address - State:LA
Mailing Address - Zip Code:70005-3756
Mailing Address - Country:US
Mailing Address - Phone:337-739-4153
Mailing Address - Fax:
Practice Address - Street 1:200 HENRY CLAY AVE
Practice Address - Street 2:
Practice Address - City:NEW ORLEANS
Practice Address - State:LA
Practice Address - Zip Code:70118-5720
Practice Address - Country:US
Practice Address - Phone:504-899-9511
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-02
Last Update Date:2011-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA2026932080N0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080N0001XAllopathic & Osteopathic PhysiciansPediatricsNeonatal-Perinatal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1982342Medicaid
LA1982342Medicaid