Provider Demographics
NPI:1225041353
Name:GUPTA, BAL KRISHAN (MD)
Entity Type:Individual
Prefix:DR
First Name:BAL
Middle Name:KRISHAN
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 1:11900 E TWELVE MILE RD
Mailing Address - Street 2:SUITE 111
Mailing Address - City:WARREN
Mailing Address - State:MI
Mailing Address - Zip Code:48093-3472
Mailing Address - Country:US
Mailing Address - Phone:586-573-5300
Mailing Address - Fax:586-573-5304
Practice Address - Street 1:11900 E TWELVE MILE RD
Practice Address - Street 2:SUITE 111
Practice Address - City:WARREN
Practice Address - State:MI
Practice Address - Zip Code:48093-3472
Practice Address - Country:US
Practice Address - Phone:586-573-5300
Practice Address - Fax:586-573-5304
Is Sole Proprietor?:No
Enumeration Date:2006-08-13
Last Update Date:2014-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI43010376332084F0202X, 2084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
No2084F0202XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyForensic Psychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1368788Medicaid
260E011140OtherBCBS
MI1368788Medicaid
OM57830Medicare ID - Type UnspecifiedGROUP
E21190Medicare UPIN