Provider Demographics
NPI:1639118516
Name:NEENA GUPTA, DO, PA/DBA SAMPLE MEDICAL CENTER
Entity Type:Organization
Organization Name:NEENA GUPTA, DO, PA/DBA SAMPLE MEDICAL CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:NEENA
Authorized Official - Middle Name:
Authorized Official - Last Name:GUPTA
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:954-968-4000
Mailing Address - Street 1:5430 W SAMPLE RD
Mailing Address - Street 2:
Mailing Address - City:MARGATE
Mailing Address - State:FL
Mailing Address - Zip Code:33073-3453
Mailing Address - Country:US
Mailing Address - Phone:954-968-4000
Mailing Address - Fax:954-968-4099
Practice Address - Street 1:5430 W SAMPLE RD
Practice Address - Street 2:
Practice Address - City:MARGATE
Practice Address - State:FL
Practice Address - Zip Code:33073-3453
Practice Address - Country:US
Practice Address - Phone:954-968-4000
Practice Address - Fax:954-968-4099
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-06
Last Update Date:2008-05-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL274556900Medicaid
FL274556900Medicaid