Provider Demographics
NPI:1437842713
Name:GUPTA, POONAM
Entity Type:Individual
Prefix:
First Name:POONAM
Middle Name:
Last Name:GUPTA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:18502 W BELLFORT ST STE 118
Mailing Address - Street 2:
Mailing Address - City:RICHMOND
Mailing Address - State:TX
Mailing Address - Zip Code:77407-9003
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:15119 WALLISVILLE RD STE 100
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77049-4629
Practice Address - Country:US
Practice Address - Phone:713-957-2552
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-06-01
Last Update Date:2023-06-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1374078225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist