Provider Demographics
NPI:1467424382
Name:GUPTA, SHAILESH K (MD)
Entity Type:Individual
Prefix:
First Name:SHAILESH
Middle Name:K
Last Name:GUPTA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:2001 W SAMPLE RD STE 320
Mailing Address - Street 2:
Mailing Address - City:DEERFIELD BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33064-1346
Mailing Address - Country:US
Mailing Address - Phone:561-322-3588
Mailing Address - Fax:754-812-5993
Practice Address - Street 1:2001 W SAMPLE RD STE 320
Practice Address - Street 2:
Practice Address - City:DEERFIELD BEACH
Practice Address - State:FL
Practice Address - Zip Code:33064-1346
Practice Address - Country:US
Practice Address - Phone:561-322-3588
Practice Address - Fax:754-812-5993
Is Sole Proprietor?:No
Enumeration Date:2006-02-03
Last Update Date:2024-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME81086207W00000X, 207WX0107X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207WX0107XAllopathic & Osteopathic PhysiciansOphthalmologyRetina Specialist
No207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL2615134-00Medicaid
GA000908102AMedicaid
FL2615134-00Medicaid
FL01666ZMedicare PIN
GA000908102AMedicaid