Provider Demographics
NPI:1356646822
Name:GUPTA, VIKAS
Entity Type:Individual
Prefix:
First Name:VIKAS
Middle Name:
Last Name:GUPTA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:610 HUNTWICK LN
Mailing Address - Street 2:
Mailing Address - City:TYLER
Mailing Address - State:TX
Mailing Address - Zip Code:75703-5099
Mailing Address - Country:US
Mailing Address - Phone:903-714-2371
Mailing Address - Fax:
Practice Address - Street 1:610 HUNTWICK LN
Practice Address - Street 2:
Practice Address - City:TYLER
Practice Address - State:TX
Practice Address - Zip Code:75703-5099
Practice Address - Country:US
Practice Address - Phone:903-714-2371
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-01-14
Last Update Date:2015-01-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX110141225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist