Provider Demographics
NPI:1891780276
Name:GUPTA-MODAK, ANJU (MD)
Entity Type:Individual
Prefix:
First Name:ANJU
Middle Name:
Last Name:GUPTA-MODAK
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 1:977 48TH ST
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11219-2919
Mailing Address - Country:US
Mailing Address - Phone:718-283-8015
Mailing Address - Fax:718-635-7235
Practice Address - Street 1:4802 10TH AVE
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11219-2844
Practice Address - Country:US
Practice Address - Phone:718-283-8853
Practice Address - Fax:718-635-7235
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-09-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY2252852080N0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080N0001XAllopathic & Osteopathic PhysiciansPediatricsNeonatal-Perinatal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY26N9651OtherNEIGHBORHOOD HEALTH
NY2603107OtherGHI
NY001131-A15OtherHEALTH FIRST
NY4C4442OtherHEALTH NET
NYGA5285OtherATLANTIS HEALTH PLAN
NYP2068431OtherOXFORD HEALTH PLANS
NY001131OtherHIP
NY02109608Medicaid
NY0B7762OtherEMPIRE BCBS
NY1000030331OtherAFFINITY HEALTH PLAN
NY0B7762Medicare ID - Type Unspecified
NY001131-A15OtherHEALTH FIRST