Provider Demographics
NPI:1033407499
Name:GUPTA, JONATHAN (MD)
Entity Type:Individual
Prefix:DR
First Name:JONATHAN
Middle Name:
Last Name:GUPTA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:32640 WHATLEY RD
Mailing Address - Street 2:
Mailing Address - City:FRANKLIN
Mailing Address - State:MI
Mailing Address - Zip Code:48025-1123
Mailing Address - Country:US
Mailing Address - Phone:248-390-0579
Mailing Address - Fax:
Practice Address - Street 1:44405 WOODWARD AVE
Practice Address - Street 2:
Practice Address - City:PONTIAC
Practice Address - State:MI
Practice Address - Zip Code:48341-5023
Practice Address - Country:US
Practice Address - Phone:248-858-3000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-07-19
Last Update Date:2017-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301099446208D00000X, 2085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
No208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice