Provider Demographics
NPI:1336250505
Name:GUPTA, MANISHA (MD)
Entity Type:Individual
Prefix:
First Name:MANISHA
Middle Name:
Last Name:GUPTA
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1000 HOUGHTON AVE
Mailing Address - Street 2:
Mailing Address - City:SAGINAW
Mailing Address - State:MI
Mailing Address - Zip Code:48602-5303
Mailing Address - Country:US
Mailing Address - Phone:989-583-6812
Mailing Address - Fax:989-583-6915
Practice Address - Street 1:1000 HOUGHTON AVE
Practice Address - Street 2:
Practice Address - City:SAGINAW
Practice Address - State:MI
Practice Address - Zip Code:48602-5303
Practice Address - Country:US
Practice Address - Phone:989-583-6812
Practice Address - Fax:989-583-6915
Is Sole Proprietor?:No
Enumeration Date:2006-08-31
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301074089207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI700G360210OtherBCBSM GROUP
MI152198OtherGREAT LAKES HEALTH PLAN
MI4791306Medicaid
MI381870664OtherTAX ID
MIMG074089OtherLICENSE
MI152198OtherGREAT LAKES HEALTH PLAN
MI0G36021038Medicare ID - Type UnspecifiedMEDICARE
MI4791306Medicaid