Provider Demographics
NPI:1376628800
Name:GUPTA, SANJAY KUMAR (MD)
Entity Type:Individual
Prefix:DR
First Name:SANJAY
Middle Name:KUMAR
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 1:18 SQUADRON BLVD
Mailing Address - Street 2:
Mailing Address - City:NEW CITY
Mailing Address - State:NY
Mailing Address - Zip Code:10956-5210
Mailing Address - Country:US
Mailing Address - Phone:845-634-9729
Mailing Address - Fax:
Practice Address - Street 1:18 SQUADRON BLVD
Practice Address - Street 2:
Practice Address - City:NEW CITY
Practice Address - State:NY
Practice Address - Zip Code:10956-5210
Practice Address - Country:US
Practice Address - Phone:845-634-9729
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-25
Last Update Date:2015-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY2279692085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02529528Medicaid
E92176Medicare UPIN
667T01Medicare ID - Type Unspecified