Provider Demographics
NPI:1194855882
Name:KAMLESH GUPTA MD
Entity Type:Organization
Organization Name:KAMLESH GUPTA MD
Other - Org Name:HALIFAX PATHOLOGY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:VIJAY
Authorized Official - Middle Name:
Authorized Official - Last Name:GUPTA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:252-586-7049
Mailing Address - Street 1:250 SMITH CHURCH RD
Mailing Address - Street 2:P.O. BOX 1107
Mailing Address - City:ROANOKE RAPIDS
Mailing Address - State:NC
Mailing Address - Zip Code:27870-4914
Mailing Address - Country:US
Mailing Address - Phone:252-586-7049
Mailing Address - Fax:
Practice Address - Street 1:250 SMITH CHURCH RD
Practice Address - Street 2:
Practice Address - City:ROANOKE RAPIDS
Practice Address - State:NC
Practice Address - Zip Code:27870-4914
Practice Address - Country:US
Practice Address - Phone:252-586-7049
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-06
Last Update Date:2008-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC26003207ZP0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical PathologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC2309165Medicare PIN
NCC82180Medicare UPIN
NC203955CMedicare ID - Type Unspecified