Provider Demographics
NPI:1376645002
Name:GUPTA, SURESH C (MD)
Entity Type:Individual
Prefix:DR
First Name:SURESH
Middle Name:C
Last Name:GUPTA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Mailing Address - Street 1:7330 SAN PEDRO AVE
Mailing Address - Street 2:STE 540
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78216-6250
Mailing Address - Country:US
Mailing Address - Phone:210-344-7287
Mailing Address - Fax:210-344-2649
Practice Address - Street 1:1510 S STATE RD
Practice Address - Street 2:SUITE A
Practice Address - City:DAVISON
Practice Address - State:MI
Practice Address - Zip Code:48423-1965
Practice Address - Country:US
Practice Address - Phone:810-653-0899
Practice Address - Fax:810-653-4144
Is Sole Proprietor?:No
Enumeration Date:2006-09-02
Last Update Date:2018-05-02
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
TXP4761207R00000X
MI4301037942207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI3235996Medicaid
MIM23560029Medicare PIN
MI3235996Medicaid