Provider Demographics
NPI:1790780963
Name:GUPTA, ANU (MD)
Entity Type:Individual
Prefix:DR
First Name:ANU
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 1:808 W DIAMOND AVE
Mailing Address - Street 2:
Mailing Address - City:GAITHERSBURG
Mailing Address - State:MD
Mailing Address - Zip Code:20878-1413
Mailing Address - Country:US
Mailing Address - Phone:240-364-0900
Mailing Address - Fax:240-364-0838
Practice Address - Street 1:808 W DIAMOND AVE
Practice Address - Street 2:
Practice Address - City:GAITHERSBURG
Practice Address - State:MD
Practice Address - Zip Code:20878-1413
Practice Address - Country:US
Practice Address - Phone:240-364-0900
Practice Address - Fax:240-364-0838
Is Sole Proprietor?:Yes
Enumeration Date:2005-06-15
Last Update Date:2012-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101053278174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA010068029Medicaid
MD223638Medicare PIN
G45033Medicare UPIN