Provider Demographics
NPI:1942238126
Name:GUPTA, MADHAVI (MD)
Entity Type:Individual
Prefix:
First Name:MADHAVI
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 1:221 S 12TH ST
Mailing Address - Street 2:APT. N607
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19107-5556
Mailing Address - Country:US
Mailing Address - Phone:646-824-3906
Mailing Address - Fax:
Practice Address - Street 1:1 MEDICAL CENTER BLVD
Practice Address - Street 2:ACP #533
Practice Address - City:UPLAND
Practice Address - State:PA
Practice Address - Zip Code:19013-3902
Practice Address - Country:US
Practice Address - Phone:610-874-1184
Practice Address - Fax:610-874-4258
Is Sole Proprietor?:No
Enumeration Date:2006-06-28
Last Update Date:2007-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD4228632084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1017194730Medicaid
104484Medicare PIN