Provider Demographics
NPI:1619067147
Name:GUPTA, SHUBHAM (MD)
Entity Type:Individual
Prefix:
First Name:SHUBHAM
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 1:4500 S LANCASTER ROAD
Mailing Address - Street 2:VETERANS AFFAIRS MEDICAL CENTER (111K)
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75216
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4500 SOUTH LANCASTER ROAD
Practice Address - Street 2:VA MEDICAL CENTER
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75216
Practice Address - Country:US
Practice Address - Phone:214-857-1580
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-13
Last Update Date:2011-05-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01061603A207R00000X
OH35.087590207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine