Provider Demographics
NPI:1477559763
Name:GUPTA, DIVYA (MD)
Entity Type:Individual
Prefix:
First Name:DIVYA
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 1:65 JAMES ST
Mailing Address - Street 2:
Mailing Address - City:EDISON
Mailing Address - State:NJ
Mailing Address - Zip Code:08820-3947
Mailing Address - Country:US
Mailing Address - Phone:732-321-7010
Mailing Address - Fax:732-744-5873
Practice Address - Street 1:65 JAMES ST
Practice Address - Street 2:
Practice Address - City:EDISON
Practice Address - State:NJ
Practice Address - Zip Code:08820-3947
Practice Address - Country:US
Practice Address - Phone:732-321-7010
Practice Address - Fax:732-744-5873
Is Sole Proprietor?:No
Enumeration Date:2005-06-22
Last Update Date:2022-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA081562002084N0400X, 2084N0600X, 2084S0012X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084S0012XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologySleep Medicine
No2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
No2084N0600XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyClinical Neurophysiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
130000567OtherUCHC, FARMINGTON, CT
130000575OtherECHN, MANCHESTER, CT
NJ0121622Medicaid
CT001401380Medicaid
NJP00571215Medicare PIN
130000575OtherECHN, MANCHESTER, CT
NJ0121622Medicaid