Provider Demographics
NPI:1972980332
Name:GUPTA, ISHA (MD)
Entity Type:Individual
Prefix:
First Name:ISHA
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 1:4360 WASHINGTON BLVD
Mailing Address - Street 2:ATTN CREDENTIALING
Mailing Address - City:OGDEN
Mailing Address - State:UT
Mailing Address - Zip Code:84403-1866
Mailing Address - Country:US
Mailing Address - Phone:801-476-0494
Mailing Address - Fax:801-479-3937
Practice Address - Street 1:4360 WASHINGTON BLVD
Practice Address - Street 2:
Practice Address - City:OGDEN
Practice Address - State:UT
Practice Address - Zip Code:84403-1866
Practice Address - Country:US
Practice Address - Phone:801-476-0494
Practice Address - Fax:801-479-3937
Is Sole Proprietor?:No
Enumeration Date:2015-05-05
Last Update Date:2023-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT12879547-1205207W00000X
TXBP10053080207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology