Provider Demographics
NPI:1639739196
Name:GUPTA, AJITA (MD)
Entity Type:Individual
Prefix:
First Name:AJITA
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 1:7575 GRAND RIVER RD STE 210
Mailing Address - Street 2:
Mailing Address - City:BRIGHTON
Mailing Address - State:MI
Mailing Address - Zip Code:48114-9379
Mailing Address - Country:US
Mailing Address - Phone:810-844-7950
Mailing Address - Fax:
Practice Address - Street 1:7575 GRAND RIVER RD STE 209
Practice Address - Street 2:
Practice Address - City:BRIGHTON
Practice Address - State:MI
Practice Address - Zip Code:48114-9379
Practice Address - Country:US
Practice Address - Phone:810-844-7950
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-06-17
Last Update Date:2020-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program