Provider Demographics
NPI:1760414122
Name:GUPTA, ANJALI
Entity Type:Individual
Prefix:
First Name:ANJALI
Middle Name:
Last Name:GUPTA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1320 S BAY ST
Mailing Address - Street 2:
Mailing Address - City:EUSTIS
Mailing Address - State:FL
Mailing Address - Zip Code:32726-5551
Mailing Address - Country:US
Mailing Address - Phone:352-530-9557
Mailing Address - Fax:352-602-7149
Practice Address - Street 1:1320 S BAY ST
Practice Address - Street 2:
Practice Address - City:EUSTIS
Practice Address - State:FL
Practice Address - Zip Code:32726-5551
Practice Address - Country:US
Practice Address - Phone:352-530-9557
Practice Address - Fax:352-602-7149
Is Sole Proprietor?:No
Enumeration Date:2006-07-07
Last Update Date:2019-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0361295882084A0401X
IA374622085R0001X
PAMD063886L2085R0001X
FLME1368792084A0401X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084A0401XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyAddiction Medicine
No2085R0001XAllopathic & Osteopathic PhysiciansRadiologyRadiation Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA70640OtherWELLMARK BCBS
FLME136879OtherMEDICAL LICENSE
PA0016869060001Medicaid
IAI21383Medicare PIN
PA006738Medicare ID - Type Unspecified
IA70640OtherWELLMARK BCBS
PA0016869060001Medicaid