Provider Demographics
NPI:1588610075
Name:SUNIL GUPTA MD LLC
Entity Type:Organization
Organization Name:SUNIL GUPTA MD LLC
Other - Org Name:RETINA SPECIALTY INSTITUTE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MANAGING MEMBER
Authorized Official - Prefix:DR
Authorized Official - First Name:SUNIL
Authorized Official - Middle Name:
Authorized Official - Last Name:GUPTA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:850-476-6759
Mailing Address - Street 1:5150 N DAVIS HWY
Mailing Address - Street 2:
Mailing Address - City:PENSACOLA
Mailing Address - State:FL
Mailing Address - Zip Code:32503-2030
Mailing Address - Country:US
Mailing Address - Phone:850-476-6759
Mailing Address - Fax:850-484-5222
Practice Address - Street 1:5150 N DAVIS HWY
Practice Address - Street 2:
Practice Address - City:PENSACOLA
Practice Address - State:FL
Practice Address - Zip Code:32503-2030
Practice Address - Country:US
Practice Address - Phone:850-476-6759
Practice Address - Fax:850-484-5222
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-26
Last Update Date:2011-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME66379207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL529917080Medicaid
FL34843OtherBLUE CROSS PROVIDER GROUP
MS09016091Medicaid
MS07331062OtherMEDICAID
FL267921300Medicaid
MS09016091Medicaid
FL34843AMedicare PIN