Provider Demographics
NPI:1265516967
Name:GUPTA, ASHISH (MD)
Entity type:Individual
Prefix:
First Name:ASHISH
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 1:2070 BIDDLE AVE STE 1
Mailing Address - Street 2:
Mailing Address - City:WYANDOTTE
Mailing Address - State:MI
Mailing Address - Zip Code:48192-4080
Mailing Address - Country:US
Mailing Address - Phone:734-283-7248
Mailing Address - Fax:734-283-2937
Practice Address - Street 1:2070 BIDDLE AVE
Practice Address - Street 2:SUITE 1
Practice Address - City:WYANDOTTE
Practice Address - State:MI
Practice Address - Zip Code:48192-4080
Practice Address - Country:US
Practice Address - Phone:734-283-7248
Practice Address - Fax:734-283-2937
Is Sole Proprietor?:No
Enumeration Date:2006-10-25
Last Update Date:2015-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301072131208600000X, 2086S0129X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086S0129XAllopathic & Osteopathic PhysiciansSurgeryVascular Surgery
No208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
151747OtherGREAT LAKES HEALTH PLAN
MI0208238992OtherBCBS
17191OtherM-CARE
141876OtherCARE CHOICES
P00248151OtherMEDICARE RAILROAD
I33940OtherHAP
MI104740862Medicaid
0P19410001Medicare PIN
I33940Medicare UPIN