Provider Demographics
NPI:1164050472
Name:GUPTA, MITALIE (MD)
Entity Type:Individual
Prefix:DR
First Name:MITALIE
Middle Name:
Last Name:GUPTA
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6044 GATEWAY BLVD E FL 9
Mailing Address - Street 2:
Mailing Address - City:EL PASO
Mailing Address - State:TX
Mailing Address - Zip Code:79905-2023
Mailing Address - Country:US
Mailing Address - Phone:915-521-1471
Mailing Address - Fax:
Practice Address - Street 1:6044 GATEWAY BLVD E FL 9
Practice Address - Street 2:
Practice Address - City:EL PASO
Practice Address - State:TX
Practice Address - Zip Code:79905-2023
Practice Address - Country:US
Practice Address - Phone:915-521-1474
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-03-31
Last Update Date:2024-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
NMMD2023-1530209800000X
TXU8063207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No209800000XAllopathic & Osteopathic PhysiciansLegal Medicine