Provider Demographics
NPI:1962462630
Name:GUPTA, AMITA (MD)
Entity Type:Individual
Prefix:
First Name:AMITA
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 1:2075 W PECOS RD
Mailing Address - Street 2:SUITE 2
Mailing Address - City:CHANDLER
Mailing Address - State:AZ
Mailing Address - Zip Code:85224-5722
Mailing Address - Country:US
Mailing Address - Phone:480-219-6840
Mailing Address - Fax:480-219-6841
Practice Address - Street 1:2075 W PECOS RD, #2
Practice Address - Street 2:
Practice Address - City:CHANDLER
Practice Address - State:AZ
Practice Address - Zip Code:85224-5693
Practice Address - Country:US
Practice Address - Phone:480-219-6840
Practice Address - Fax:480-219-6841
Is Sole Proprietor?:No
Enumeration Date:2006-03-25
Last Update Date:2011-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ33008207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZAZ0759120OtherBC/BS OF AZ
AZP00279971OtherRR MEDICARE
AZ866973Medicaid
AZZ107794Medicare PIN
AZI10143Medicare UPIN
AZ866973Medicaid