Provider Demographics
NPI:1437255338
Name:GUPTA, SHAKUNMALA (MD)
Entity Type:Individual
Prefix:
First Name:SHAKUNMALA
Middle Name:
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:PO BOX 6303
Mailing Address - Street 2:
Mailing Address - City:ELLICOTT CITY
Mailing Address - State:MD
Mailing Address - Zip Code:21042-0303
Mailing Address - Country:US
Mailing Address - Phone:410-992-7004
Mailing Address - Fax:
Practice Address - Street 1:9650 SANTIAGO RD
Practice Address - Street 2:SUITE 110
Practice Address - City:COLUMBIA
Practice Address - State:MD
Practice Address - Zip Code:21045-3957
Practice Address - Country:US
Practice Address - Phone:410-992-7004
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-16
Last Update Date:2019-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD0053150207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD241500300Medicaid
H08626Medicare UPIN
MD961MK762Medicare ID - Type Unspecified
MD241500300Medicaid