Provider Demographics
NPI:1477562536
Name:SANJIV GUPTA M.D. P.S.C.
Entity Type:Organization
Organization Name:SANJIV GUPTA M.D. P.S.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:SANJIV
Authorized Official - Middle Name:
Authorized Official - Last Name:GUPTA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:606-474-2200
Mailing Address - Street 1:PO BOX 1620
Mailing Address - Street 2:300 ST HWY 1947
Mailing Address - City:GRAYSON
Mailing Address - State:KY
Mailing Address - Zip Code:41143-5620
Mailing Address - Country:US
Mailing Address - Phone:606-474-2200
Mailing Address - Fax:606-474-2205
Practice Address - Street 1:300 ST HWY 1947
Practice Address - Street 2:SUITE A
Practice Address - City:GRAYSON
Practice Address - State:KY
Practice Address - Zip Code:41143-1947
Practice Address - Country:US
Practice Address - Phone:606-474-2200
Practice Address - Fax:606-474-2205
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-07
Last Update Date:2020-04-28
Deactivation Date:2007-07-02
Deactivation Code:
Reactivation Date:2007-11-09
Provider Licenses
StateLicense IDTaxonomies
KY32686207R00000X, 332B00000X
207RA0401X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No207RA0401XAllopathic & Osteopathic PhysiciansInternal MedicineAddiction MedicineGroup - Multi-Specialty
No332B00000XSuppliersDurable Medical Equipment & Medical SuppliesGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2016446Medicaid
KY64326861Medicaid
G43693Medicare UPIN
OH2016446Medicaid