Provider Demographics
NPI:1457681041
Name:GUPTA, SUMAN (MD)
Entity Type:Individual
Prefix:
First Name:SUMAN
Middle Name:
Last Name:GUPTA
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:SUMAN
Other - Middle Name:
Other - Last Name:GUPTA
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:850 W PLYMOUTH AVE
Mailing Address - Street 2:
Mailing Address - City:DELAND
Mailing Address - State:FL
Mailing Address - Zip Code:32720-3284
Mailing Address - Country:US
Mailing Address - Phone:386-736-6110
Mailing Address - Fax:386-736-7998
Practice Address - Street 1:850 W. PLYMOUTH AVE
Practice Address - Street 2:
Practice Address - City:DELAND
Practice Address - State:FL
Practice Address - Zip Code:32720
Practice Address - Country:US
Practice Address - Phone:386-736-6110
Practice Address - Fax:386-736-7998
Is Sole Proprietor?:No
Enumeration Date:2010-01-05
Last Update Date:2012-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME106178174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL253359600Medicaid
FL253359600Medicaid