Provider Demographics
NPI:1013992528
Name:GUPTA, ROM M (MD)
Entity Type:Individual
Prefix:DR
First Name:ROM
Middle Name:M
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 1:17561 HILLSIDE AVE STE 402
Mailing Address - Street 2:
Mailing Address - City:JAMAICA
Mailing Address - State:NY
Mailing Address - Zip Code:11432-5769
Mailing Address - Country:US
Mailing Address - Phone:718-291-0488
Mailing Address - Fax:718-291-0888
Practice Address - Street 1:17561 HILLSIDE AVE STE 402
Practice Address - Street 2:
Practice Address - City:JAMAICA
Practice Address - State:NY
Practice Address - Zip Code:11432-5769
Practice Address - Country:US
Practice Address - Phone:718-291-0488
Practice Address - Fax:718-291-0888
Is Sole Proprietor?:Yes
Enumeration Date:2005-12-07
Last Update Date:2020-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY189770207R00000X, 207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01417876Medicaid
NYWEJ611Medicare PIN
NYF39166Medicare UPIN
NY08I381Medicare ID - Type Unspecified
NY01358Medicare PIN