Provider Demographics
NPI:1568608198
Name:GUPTA, ASHUTOSH (MD)
Entity Type:Individual
Prefix:
First Name:ASHUTOSH
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:PO BOX 2129
Mailing Address - Street 2:
Mailing Address - City:ODESSA
Mailing Address - State:TX
Mailing Address - Zip Code:79760-2129
Mailing Address - Country:US
Mailing Address - Phone:432-640-3007
Mailing Address - Fax:432-640-2708
Practice Address - Street 1:540 W 5TH ST
Practice Address - Street 2:SUITE 300
Practice Address - City:ODESSA
Practice Address - State:TX
Practice Address - Zip Code:79761-5034
Practice Address - Country:US
Practice Address - Phone:432-640-3007
Practice Address - Fax:432-640-2708
Is Sole Proprietor?:No
Enumeration Date:2009-01-03
Last Update Date:2015-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXQ1410207RG0100X, 207RG0100X
IL125054372207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN201024310Medicaid
INP01002367OtherRAILROAD MEDICARE PTAN
IN201024310Medicaid