Provider Demographics
NPI:1174660278
Name:GUPTA, AMITABH (MD PHD)
Entity Type:Individual
Prefix:
First Name:AMITABH
Middle Name:
Last Name:GUPTA
Suffix:
Gender:M
Credentials:MD PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8198 WALNUT HILL LN STE 100
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75231-4316
Mailing Address - Country:US
Mailing Address - Phone:214-345-4440
Mailing Address - Fax:214-345-4286
Practice Address - Street 1:8198 WALNUT HILL LN STE 100
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75231
Practice Address - Country:US
Practice Address - Phone:214-345-4440
Practice Address - Fax:214-345-4286
Is Sole Proprietor?:No
Enumeration Date:2007-01-30
Last Update Date:2018-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS04-415022084N0400X
ORMD1844242084N0400X
FLME1031122084N0400X, 208M00000X
TN565382084N0400X
MDT49282084N0400X
WI698112084N0400X
TXP50742084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
No208M00000XAllopathic & Osteopathic PhysiciansHospitalist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL020725800Medicaid
FLFO946YOtherMEDICARE
FLFO946YOtherMEDICARE