Provider Demographics
NPI:1558360693
Name:GUPTA, SANJEEV (MD)
Entity Type:Individual
Prefix:MR
First Name:SANJEEV
Middle Name:
Last Name:GUPTA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:31 HOSPITAL DR
Mailing Address - Street 2:
Mailing Address - City:MASSENA
Mailing Address - State:NY
Mailing Address - Zip Code:13662
Mailing Address - Country:US
Mailing Address - Phone:315-769-1099
Mailing Address - Fax:315-769-1077
Practice Address - Street 1:31 HOSPITAL DR
Practice Address - Street 2:
Practice Address - City:MASSENA
Practice Address - State:NY
Practice Address - Zip Code:13662
Practice Address - Country:US
Practice Address - Phone:315-769-1099
Practice Address - Fax:315-769-1077
Is Sole Proprietor?:No
Enumeration Date:2005-07-20
Last Update Date:2014-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY2105112080A0000X, 208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
No2080A0000XAllopathic & Osteopathic PhysiciansPediatricsAdolescent Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01647974Medicaid