Provider Demographics
NPI:1356572853
Name:GUPTA, AMIT (PT)
Entity type:Individual
Prefix:
First Name:AMIT
Middle Name:
Last Name:GUPTA
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:540 S PARKER ST
Mailing Address - Street 2:SUITE B
Mailing Address - City:MARINE CITY
Mailing Address - State:MI
Mailing Address - Zip Code:48039-3593
Mailing Address - Country:US
Mailing Address - Phone:810-765-8110
Mailing Address - Fax:810-765-9811
Practice Address - Street 1:540 S PARKER ST
Practice Address - Street 2:SUITE B
Practice Address - City:MARINE CITY
Practice Address - State:MI
Practice Address - Zip Code:48039-3593
Practice Address - Country:US
Practice Address - Phone:810-765-8110
Practice Address - Fax:810-765-9811
Is Sole Proprietor?:No
Enumeration Date:2009-07-31
Last Update Date:2009-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5501013632225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist