Provider Demographics
NPI:1487643342
Name:GUPTA, SURYA N (MD)
Entity Type:Individual
Prefix:
First Name:SURYA
Middle Name:N
Last Name:GUPTA
Suffix:
Gender:M
Credentials:MD
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Mailing Address - Street 1:PO BOX 1547
Mailing Address - Street 2:CAMC PEDIATRIC NEUROLOGY
Mailing Address - City:CHARLESTON
Mailing Address - State:WV
Mailing Address - Zip Code:25326-1547
Mailing Address - Country:US
Mailing Address - Phone:304-388-7183
Mailing Address - Fax:304-388-7176
Practice Address - Street 1:4803 KENTUCKY STREET
Practice Address - Street 2:CAMC PEDIATRIC NEUROLOGY
Practice Address - City:SOUTH CHARLESTON
Practice Address - State:WV
Practice Address - Zip Code:25309-1547
Practice Address - Country:US
Practice Address - Phone:304-766-7695
Practice Address - Fax:603-663-3229
Is Sole Proprietor?:No
Enumeration Date:2005-10-13
Last Update Date:2013-07-18
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Provider Licenses
StateLicense IDTaxonomies
PAMD057895L2080P0008X
NH150262084N0402X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0402XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology with Special Qualifications in Child Neurology
No2080P0008XAllopathic & Osteopathic PhysiciansPediatricsNeurodevelopmental Disabilities
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0016630190001Medicaid
H98608Medicare UPIN
905524Medicare ID - Type Unspecified