Provider Demographics
NPI:1326411232
Name:GUPTA, KSHITIJ (MD)
Entity Type:Individual
Prefix:
First Name:KSHITIJ
Middle Name:
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 1:3636 WALDO AVE APT 1G
Mailing Address - Street 2:
Mailing Address - City:BRONX
Mailing Address - State:NY
Mailing Address - Zip Code:10463-2248
Mailing Address - Country:US
Mailing Address - Phone:646-726-8263
Mailing Address - Fax:
Practice Address - Street 1:303 E MATTHEWS AVE STE 202
Practice Address - Street 2:
Practice Address - City:JONESBORO
Practice Address - State:AR
Practice Address - Zip Code:72401-3120
Practice Address - Country:US
Practice Address - Phone:870-207-7555
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-11-02
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
ARE10045207RG0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0300XAllopathic & Osteopathic PhysiciansInternal MedicineGeriatric Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
ARE-10045OtherAR STATE LICENSE
FG6418544OtherDEA
AR555758ZQQ9Medicare PIN