Provider Demographics
NPI:1942244439
Name:GUPTA, VIVEK (MD)
Entity Type:Individual
Prefix:
First Name:VIVEK
Middle Name:
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 1:6610 TURNSTONE LN
Mailing Address - Street 2:
Mailing Address - City:LAKEWOOD RANCH
Mailing Address - State:FL
Mailing Address - Zip Code:34202-8291
Mailing Address - Country:US
Mailing Address - Phone:941-315-1919
Mailing Address - Fax:
Practice Address - Street 1:2109 60TH ST W
Practice Address - Street 2:
Practice Address - City:BRADENTON
Practice Address - State:FL
Practice Address - Zip Code:34209-5526
Practice Address - Country:US
Practice Address - Phone:941-315-1919
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-15
Last Update Date:2011-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME942152085N0904X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085N0904XAllopathic & Osteopathic PhysiciansRadiologyNuclear Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL002542500Medicaid
FLU6375VMedicare PIN
FLU63752Medicare ID - Type UnspecifiedMEDICARE PROVIDER NUMBER
FL002542500Medicaid