Provider Demographics
NPI:1164415105
Name:GUPTA, KAMAL A (MD)
Entity Type:Individual
Prefix:DR
First Name:KAMAL
Middle Name:A
Last Name:GUPTA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:19335 ALLEN RD
Mailing Address - Street 2:
Mailing Address - City:BROWNSTOWN TWP
Mailing Address - State:MI
Mailing Address - Zip Code:48183-1003
Mailing Address - Country:US
Mailing Address - Phone:734-479-5580
Mailing Address - Fax:734-479-5586
Practice Address - Street 1:19335 ALLEN RD
Practice Address - Street 2:
Practice Address - City:BROWNSTOWN TWP
Practice Address - State:MI
Practice Address - Zip Code:48183-1003
Practice Address - Country:US
Practice Address - Phone:734-479-5580
Practice Address - Fax:734-479-5586
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-08-24
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI2844198Medicaid
MI0635960Medicare ID - Type Unspecified
MIE64376Medicare UPIN