Provider Demographics
NPI:1619936069
Name:GUPTA, DEEPTI (MD)
Entity Type:Individual
Prefix:
First Name:DEEPTI
Middle Name:
Last Name:GUPTA
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2 MEDICAL DR
Mailing Address - Street 2:STE D
Mailing Address - City:PORT JEFFERSON STATION
Mailing Address - State:NY
Mailing Address - Zip Code:11776-1598
Mailing Address - Country:US
Mailing Address - Phone:631-331-5010
Mailing Address - Fax:631-331-5017
Practice Address - Street 1:2 MEDICAL DR
Practice Address - Street 2:STE D
Practice Address - City:PORT JEFFERSON STATION
Practice Address - State:NY
Practice Address - Zip Code:11776-1598
Practice Address - Country:US
Practice Address - Phone:631-331-5010
Practice Address - Fax:631-331-5017
Is Sole Proprietor?:Yes
Enumeration Date:2006-03-22
Last Update Date:2017-07-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY196816207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01593246Medicaid
NY01593246Medicaid
NYG16079Medicare UPIN