Provider Demographics
NPI:1386677250
Name:GUPTA, PREM P (MD)
Entity Type:Individual
Prefix:DR
First Name:PREM
Middle Name:P
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 1:12398 FM 423 STE 600
Mailing Address - Street 2:
Mailing Address - City:FRISCO
Mailing Address - State:TX
Mailing Address - Zip Code:75033-0158
Mailing Address - Country:US
Mailing Address - Phone:214-494-4622
Mailing Address - Fax:214-494-4609
Practice Address - Street 1:12398 FM 423 STE 600
Practice Address - Street 2:
Practice Address - City:FRISCO
Practice Address - State:TX
Practice Address - Zip Code:75033-0158
Practice Address - Country:US
Practice Address - Phone:214-494-4622
Practice Address - Fax:214-494-4609
Is Sole Proprietor?:No
Enumeration Date:2006-07-07
Last Update Date:2012-05-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXF7772208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX4403201OtherAETNA ID
TX114191103OtherFIRSTCARE HMO
TX101054OtherSUPERIOR HEALTHPLAN
TX8H3960OtherBCBS TX
TX133070608Medicaid
TX155931202Medicaid
TX133070608Medicaid
TX155931202Medicaid