Provider Demographics
NPI:1851398820
Name:GUPTA, CHANDRA M (MD)
Entity Type:Individual
Prefix:DR
First Name:CHANDRA
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 1:101 DOUGHTY BLVD
Mailing Address - Street 2:
Mailing Address - City:INWOOD
Mailing Address - State:NY
Mailing Address - Zip Code:11096-2003
Mailing Address - Country:US
Mailing Address - Phone:516-239-2924
Mailing Address - Fax:516-239-1609
Practice Address - Street 1:101 DOUGHTY BLVD
Practice Address - Street 2:
Practice Address - City:INWOOD
Practice Address - State:NY
Practice Address - Zip Code:11096-2003
Practice Address - Country:US
Practice Address - Phone:516-239-2924
Practice Address - Fax:516-239-1609
Is Sole Proprietor?:Yes
Enumeration Date:2005-07-05
Last Update Date:2010-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY112347207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00203310Medicaid
NY00203310Medicaid
NY899741Medicare ID - Type Unspecified