Provider Demographics
NPI:1619089000
Name:GUPTA, GHANSHYAM (MD)
Entity Type:Individual
Prefix:DR
First Name:GHANSHYAM
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 60410
Mailing Address - Street 2:
Mailing Address - City:POTOMAC
Mailing Address - State:MD
Mailing Address - Zip Code:20859-0410
Mailing Address - Country:US
Mailing Address - Phone:301-838-4224
Mailing Address - Fax:301-838-4244
Practice Address - Street 1:10110 MOLECULAR DR STE 111
Practice Address - Street 2:
Practice Address - City:ROCKVILLE
Practice Address - State:MD
Practice Address - Zip Code:20850-7538
Practice Address - Country:US
Practice Address - Phone:301-838-4224
Practice Address - Fax:301-838-4244
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-31
Last Update Date:2017-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD0046398207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
Provider Identifiers
StateIdentifier IDID TypeIssuer
DC026309900Medicaid
MD53363801OtherBC.BS.
MD407274000Medicaid
DCB0750001OtherBC.BS.
DCB0750001OtherBC.BS.