Provider Demographics
NPI:1295781078
Name:GUPTA, SHAILESH (MD)
Entity type:Individual
Prefix:
First Name:SHAILESH
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 1:12 CADENA DR
Mailing Address - Street 2:
Mailing Address - City:GALVESTON
Mailing Address - State:TX
Mailing Address - Zip Code:77554-6329
Mailing Address - Country:US
Mailing Address - Phone:409-740-1558
Mailing Address - Fax:409-740-1558
Practice Address - Street 1:12 CADENA DR
Practice Address - Street 2:
Practice Address - City:GALVESTON
Practice Address - State:TX
Practice Address - Zip Code:77554-6329
Practice Address - Country:US
Practice Address - Phone:409-740-1558
Practice Address - Fax:409-740-1558
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-25
Last Update Date:2007-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01054492A2085R0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0001XAllopathic & Osteopathic PhysiciansRadiologyRadiation Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200533870Medicaid
IN11501477OtherCAQH NUMBER
INF32231Medicare UPIN
IN815450ZMedicare PIN