Provider Demographics
NPI:1700885100
Name:GUPTA, BHAWNA (MD)
Entity Type:Individual
Prefix:
First Name:BHAWNA
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 1:9 WASHINGTON AVE
Mailing Address - Street 2:STE # 2D
Mailing Address - City:HAMDEN
Mailing Address - State:CT
Mailing Address - Zip Code:06518-3267
Mailing Address - Country:US
Mailing Address - Phone:203-371-7177
Mailing Address - Fax:
Practice Address - Street 1:5520 PARK AVE
Practice Address - Street 2:STE. 206
Practice Address - City:TRUMBULL
Practice Address - State:CT
Practice Address - Zip Code:06611-3463
Practice Address - Country:US
Practice Address - Phone:203-371-7177
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-07-18
Last Update Date:2014-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT45710207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT45710OtherCT STATE LICENSE
41293Medicare ID - Type Unspecified
CT45710OtherCT STATE LICENSE