Provider Demographics
NPI:1003807397
Name:GUPTA, KRISHANU BAPPA (MD, PHD)
Entity Type:Individual
Prefix:
First Name:KRISHANU
Middle Name:BAPPA
Last Name:GUPTA
Suffix:
Gender:M
Credentials:MD, PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:525 BROAD ST
Mailing Address - Street 2:SUITE 202
Mailing Address - City:CUMBERLAND
Mailing Address - State:RI
Mailing Address - Zip Code:02864-6919
Mailing Address - Country:US
Mailing Address - Phone:401-727-4600
Mailing Address - Fax:401-727-4690
Practice Address - Street 1:525 BROAD ST
Practice Address - Street 2:SUITE 202
Practice Address - City:CUMBERLAND
Practice Address - State:RI
Practice Address - Zip Code:02864-6919
Practice Address - Country:US
Practice Address - Phone:401-727-4600
Practice Address - Fax:401-727-4690
Is Sole Proprietor?:No
Enumeration Date:2005-11-04
Last Update Date:2011-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RIMD110802085R0202X
MA2106052085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
RI7010331Medicaid
RI21093-9OtherBCBS - RI
RI16-00084OtherUNITED HEALTHCARE
RI21093-9OtherBCBS - RI
RIH55928Medicare UPIN