Provider Demographics
NPI:1629046420
Name:GUPTA, VICRAM (MD)
Entity Type:Individual
Prefix:
First Name:VICRAM
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 1:902 N RIVERSIDE RD
Mailing Address - Street 2:STE 200
Mailing Address - City:ST JOSEPH
Mailing Address - State:MO
Mailing Address - Zip Code:64507-2559
Mailing Address - Country:US
Mailing Address - Phone:816-271-1301
Mailing Address - Fax:816-271-1302
Practice Address - Street 1:902 N RIVERSIDE RD
Practice Address - Street 2:STE 200
Practice Address - City:ST JOSEPH
Practice Address - State:MO
Practice Address - Zip Code:64507-2559
Practice Address - Country:US
Practice Address - Phone:816-271-1301
Practice Address - Fax:816-271-1302
Is Sole Proprietor?:No
Enumeration Date:2006-03-09
Last Update Date:2017-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS0427852207RX0202X
MO107588207RX0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RX0202XAllopathic & Osteopathic PhysiciansInternal MedicineMedical Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO1629046420Medicaid
MO21958014OtherBLUE CROSS BLUE SHIELD
KS056938OtherBCBS OF KS FOR KS LOCATIO
KS704173OtherBCBS OF KS FOR MO LOCATIO
MOP00859658OtherRR MEDICARE
KS100173870CMedicaid
KS704173OtherBCBS OF KS FOR MO LOCATIO
MOP00859658OtherRR MEDICARE
MOMA2554002Medicare PIN