Provider Demographics
NPI:1346202553
Name:GUPTA, PRABHA UGALAT (MD)
Entity Type:Individual
Prefix:
First Name:PRABHA
Middle Name:UGALAT
Last Name:GUPTA
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:700 24TH ST
Mailing Address - Street 2:
Mailing Address - City:FORT LEE
Mailing Address - State:VA
Mailing Address - Zip Code:23801-1716
Mailing Address - Country:US
Mailing Address - Phone:804-734-9993
Mailing Address - Fax:877-874-1008
Practice Address - Street 1:700 24TH ST
Practice Address - Street 2:
Practice Address - City:FORT LEE
Practice Address - State:VA
Practice Address - Zip Code:23801-1716
Practice Address - Country:US
Practice Address - Phone:804-734-9993
Practice Address - Fax:877-874-1008
Is Sole Proprietor?:No
Enumeration Date:2006-04-04
Last Update Date:2015-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101237185207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
185140OtherANTHEM
VA010203121Medicaid
I41280Medicare UPIN
185140OtherANTHEM