Provider Demographics
NPI:1568490944
Name:GUPTA, ANIL KUMAR (MD)
Entity Type:Individual
Prefix:
First Name:ANIL
Middle Name:KUMAR
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 1:3312 N OAK ST EXT BLDG D
Mailing Address - Street 2:
Mailing Address - City:VALDOSTA
Mailing Address - State:GA
Mailing Address - Zip Code:31605-1066
Mailing Address - Country:US
Mailing Address - Phone:229-244-2030
Mailing Address - Fax:229-244-2038
Practice Address - Street 1:3312 N OAK ST EXT BLDG D
Practice Address - Street 2:
Practice Address - City:VALDOSTA
Practice Address - State:GA
Practice Address - Zip Code:31605-1066
Practice Address - Country:US
Practice Address - Phone:229-244-2030
Practice Address - Fax:229-244-2038
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-28
Last Update Date:2020-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA0454872084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000934975JMedicaid
GAE48367Medicare UPIN
GA000934975JMedicaid