Provider Demographics
NPI:1114936713
Name:GUPTA, SUDEEP (DO)
Entity Type:Individual
Prefix:
First Name:SUDEEP
Middle Name:
Last Name:GUPTA
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1475
Mailing Address - Street 2:
Mailing Address - City:DES MOINES
Mailing Address - State:IA
Mailing Address - Zip Code:50305-1475
Mailing Address - Country:US
Mailing Address - Phone:515-271-6333
Mailing Address - Fax:515-271-6175
Practice Address - Street 1:4326 HICKMAN RD
Practice Address - Street 2:SUITE 100
Practice Address - City:DES MOINES
Practice Address - State:IA
Practice Address - Zip Code:50310-3333
Practice Address - Country:US
Practice Address - Phone:515-271-6333
Practice Address - Fax:515-271-6175
Is Sole Proprietor?:No
Enumeration Date:2006-08-05
Last Update Date:2020-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA03098207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA0171769Medicaid
IA0171769Medicaid
IA45864Medicare ID - Type Unspecified