Provider Demographics
NPI:1134114507
Name:SURESH C GUPTA MD PA
Entity Type:Organization
Organization Name:SURESH C GUPTA MD PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN/PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:SURESH
Authorized Official - Middle Name:C
Authorized Official - Last Name:GUPTA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:301-864-1133
Mailing Address - Street 1:3503 PERRY ST
Mailing Address - Street 2:
Mailing Address - City:MOUNT RAINIER
Mailing Address - State:MD
Mailing Address - Zip Code:20712-2141
Mailing Address - Country:US
Mailing Address - Phone:301-864-1133
Mailing Address - Fax:301-864-2155
Practice Address - Street 1:11119 ROCKVILLE PIKE STE 105
Practice Address - Street 2:
Practice Address - City:ROCKVILLE
Practice Address - State:MD
Practice Address - Zip Code:20852-3143
Practice Address - Country:US
Practice Address - Phone:301-816-2830
Practice Address - Fax:301-816-3236
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-09-13
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD14876207RP1001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary DiseaseGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD017201400Medicaid
161298Medicare ID - Type Unspecified
MD017201400Medicaid