Provider Demographics
NPI:1467569681
Name:GUPTA, MANMOHAN (MD)
Entity Type:Individual
Prefix:
First Name:MANMOHAN
Middle Name:
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:PO BOX 13026
Mailing Address - Street 2:770 PINE STREET SUITE 440
Mailing Address - City:MACON
Mailing Address - State:GA
Mailing Address - Zip Code:31208-3026
Mailing Address - Country:US
Mailing Address - Phone:478-741-4588
Mailing Address - Fax:478-741-4589
Practice Address - Street 1:770 PINE ST
Practice Address - Street 2:SUITE 440
Practice Address - City:MACON
Practice Address - State:GA
Practice Address - Zip Code:31201-2173
Practice Address - Country:US
Practice Address - Phone:478-741-4588
Practice Address - Fax:478-741-4589
Is Sole Proprietor?:No
Enumeration Date:2006-08-24
Last Update Date:2007-07-08
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
GA023976207RR0500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RR0500XAllopathic & Osteopathic PhysiciansInternal MedicineRheumatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAD40036Medicare UPIN