Provider Demographics
NPI:1790717528
Name:GUPTA, MANJU (MD)
Entity Type:Individual
Prefix:DR
First Name:MANJU
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 1:332 LAFAYETTE AVENUE
Mailing Address - Street 2:
Mailing Address - City:HAWTHORNE
Mailing Address - State:NJ
Mailing Address - Zip Code:07506
Mailing Address - Country:US
Mailing Address - Phone:973-423-0145
Mailing Address - Fax:973-423-0667
Practice Address - Street 1:332 LAFAYETTE AVENUE
Practice Address - Street 2:
Practice Address - City:HAWTHORNE
Practice Address - State:NJ
Practice Address - Zip Code:07506
Practice Address - Country:US
Practice Address - Phone:973-423-0145
Practice Address - Fax:973-423-0667
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-06
Last Update Date:2012-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJMA42995207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ0898503Medicaid
NJGU400748Medicare ID - Type Unspecified
NJ0898503Medicaid