Provider Demographics
NPI:1336749902
Name:GUPTA, VASUDHA
Entity Type:Individual
Prefix:
First Name:VASUDHA
Middle Name:
Last Name:GUPTA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:SUE
Other - Middle Name:
Other - Last Name:GUPTA
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:
Mailing Address - Street 1:6623 TUNLAW COURT
Mailing Address - Street 2:
Mailing Address - City:ALEXANDRIA
Mailing Address - State:VA
Mailing Address - Zip Code:22312
Mailing Address - Country:US
Mailing Address - Phone:703-609-6909
Mailing Address - Fax:
Practice Address - Street 1:1245 JEFFERSON DAVIS HWY
Practice Address - Street 2:
Practice Address - City:FREDERICKSBURG
Practice Address - State:VA
Practice Address - Zip Code:22401-4415
Practice Address - Country:US
Practice Address - Phone:540-371-7790
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-10-31
Last Update Date:2020-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0202011930183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist