Provider Demographics
NPI:1083824817
Name:GUPTA, AMOL K (MD)
Entity Type:Individual
Prefix:
First Name:AMOL
Middle Name:K
Last Name:GUPTA
Suffix:
Gender:M
Credentials:MD
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Mailing Address - Street 1:345 CLYDE MORRIS BLVD
Mailing Address - Street 2:SUITE 390
Mailing Address - City:ORMOND BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32174-3111
Mailing Address - Country:US
Mailing Address - Phone:386-673-0075
Mailing Address - Fax:386-673-0049
Practice Address - Street 1:345 CLYDE MORRIS BLVD
Practice Address - Street 2:SUITE 390
Practice Address - City:ORMOND BEACH
Practice Address - State:FL
Practice Address - Zip Code:32174-3111
Practice Address - Country:US
Practice Address - Phone:386-673-0075
Practice Address - Fax:386-673-0049
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-23
Last Update Date:2008-04-10
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
FLME97749208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLAI114ZMedicare PIN
FLAI115Medicare PIN