Provider Demographics
NPI:1023192077
Name:GUPTA, GAYATRI (MD)
Entity Type:Individual
Prefix:
First Name:GAYATRI
Middle Name:
Last Name: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 1:845 PALMER AVE
Mailing Address - Street 2:
Mailing Address - City:MAMARONECK
Mailing Address - State:NY
Mailing Address - Zip Code:10543-2406
Mailing Address - Country:US
Mailing Address - Phone:914-864-5672
Mailing Address - Fax:
Practice Address - Street 1:11 CRYSTAL SPRING RD
Practice Address - Street 2:
Practice Address - City:CHAPPAQUA
Practice Address - State:NY
Practice Address - Zip Code:10514-1412
Practice Address - Country:US
Practice Address - Phone:914-438-2703
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-25
Last Update Date:2009-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY252346207RG0300X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No207RG0300XAllopathic & Osteopathic PhysiciansInternal MedicineGeriatric Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
H24133Medicare UPIN
NY858131Medicare ID - Type Unspecified