Provider Demographics
NPI:1639145352
Name:GUPTA, BRIJENDRA K (MD)
Entity Type:Individual
Prefix:DR
First Name:BRIJENDRA
Middle Name:K
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 1:2585 HERSCHEL ST
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32204-4557
Mailing Address - Country:US
Mailing Address - Phone:904-388-2678
Mailing Address - Fax:904-388-6776
Practice Address - Street 1:2585 HERSCHEL ST
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32204-4557
Practice Address - Country:US
Practice Address - Phone:904-388-2678
Practice Address - Fax:904-388-6776
Is Sole Proprietor?:No
Enumeration Date:2006-02-23
Last Update Date:2021-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME93901207RN0300X, 174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrology
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL273423100Medicaid
FL273423100Medicaid
FLU5532ZMedicare PIN