Provider Demographics
NPI:1134308109
Name:GUPTA, PREM K (MD)
Entity Type:Individual
Prefix:MR
First Name:PREM
Middle Name:K
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 1:4709 FT HAMILTON PARKWAY
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11219-2927
Mailing Address - Country:US
Mailing Address - Phone:718-633-4244
Mailing Address - Fax:718-437-1556
Practice Address - Street 1:4709 FT HAMILTON PARKWAY
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11219-2927
Practice Address - Country:US
Practice Address - Phone:718-633-4244
Practice Address - Fax:718-437-1556
Is Sole Proprietor?:Yes
Enumeration Date:2007-10-26
Last Update Date:2007-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY108782207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00192548Medicaid
NY289631Medicare PIN
NYC07847Medicare UPIN