Provider Demographics
NPI:1982641049
Name:GUPTA, PRANAY (MD)
Entity Type:Individual
Prefix:
First Name:PRANAY
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 1:809 CLUB RIDGE CT
Mailing Address - Street 2:
Mailing Address - City:CHESTER
Mailing Address - State:VA
Mailing Address - Zip Code:23836-2745
Mailing Address - Country:US
Mailing Address - Phone:804-243-2020
Mailing Address - Fax:804-754-1428
Practice Address - Street 1:3660 BOULEVARD
Practice Address - Street 2:
Practice Address - City:COLONIAL HEIGHTS
Practice Address - State:VA
Practice Address - Zip Code:23834-1345
Practice Address - Country:US
Practice Address - Phone:804-243-2020
Practice Address - Fax:804-754-1428
Is Sole Proprietor?:No
Enumeration Date:2006-05-31
Last Update Date:2008-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101230970207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA6304559Medicaid
VAH39147Medicare UPIN
VA6304559Medicaid