Provider Demographics
NPI:1760483895
Name:GUPTA, SIMHADRI M (MD)
Entity Type:Individual
Prefix:DR
First Name:SIMHADRI
Middle Name:M
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:PO BOX 897
Mailing Address - Street 2:
Mailing Address - City:PISCATAWAY
Mailing Address - State:NJ
Mailing Address - Zip Code:08855-0897
Mailing Address - Country:US
Mailing Address - Phone:732-421-8422
Mailing Address - Fax:
Practice Address - Street 1:2 LINCOLN HWY
Practice Address - Street 2:SUITE 302
Practice Address - City:EDISON
Practice Address - State:NJ
Practice Address - Zip Code:08820-3961
Practice Address - Country:US
Practice Address - Phone:732-421-8422
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-10
Last Update Date:2008-08-27
Deactivation Date:2006-01-19
Deactivation Code:
Reactivation Date:2006-03-29
Provider Licenses
StateLicense IDTaxonomies
NJ25MA065737002084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJF74866Medicare UPIN
NJ051387UX9Medicare ID - Type Unspecified