Provider Demographics
NPI:1023458098
Name:GUPTA, ISHAAN (MD)
Entity type:Individual
Prefix:
First Name:ISHAAN
Middle Name:
Last Name:GUPTA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5601 LOCH RAVEN BLVD
Mailing Address - Street 2:RMB 502
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21239-2945
Mailing Address - Country:US
Mailing Address - Phone:443-444-4863
Mailing Address - Fax:443-444-4997
Practice Address - Street 1:5601 LOCH RAVEN BLVD
Practice Address - Street 2:RMB 502
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21239-2945
Practice Address - Country:US
Practice Address - Phone:443-444-4863
Practice Address - Fax:443-444-4997
Is Sole Proprietor?:No
Enumeration Date:2013-07-04
Last Update Date:2017-05-12
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MDD81650207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD514487Y82Medicare PIN