Provider Demographics
NPI:1659357523
Name:GUPTA, SUNIL (MD)
Entity Type:Individual
Prefix:DR
First Name:SUNIL
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 1:19415 DEERFIELD AVE
Mailing Address - Street 2:STE 303
Mailing Address - City:LEESBURG
Mailing Address - State:VA
Mailing Address - Zip Code:20176-8472
Mailing Address - Country:US
Mailing Address - Phone:703-297-4865
Mailing Address - Fax:703-858-7740
Practice Address - Street 1:19415 DEERFIELD AVE
Practice Address - Street 2:SUITE 303
Practice Address - City:LEESBURG
Practice Address - State:VA
Practice Address - Zip Code:20176-8472
Practice Address - Country:US
Practice Address - Phone:703-297-4865
Practice Address - Fax:703-858-7740
Is Sole Proprietor?:Yes
Enumeration Date:2005-12-21
Last Update Date:2016-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101038914208000000X, 2080N0001X, 208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
No2080N0001XAllopathic & Osteopathic PhysiciansPediatricsNeonatal-Perinatal Medicine
No208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA1659357523Medicaid
VA1659357523Medicaid