Provider Demographics
NPI:1720104052
Name:MOHINDER GUPTA MD
Entity Type:Organization
Organization Name:MOHINDER GUPTA MD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SOLE PROPRIETOR
Authorized Official - Prefix:
Authorized Official - First Name:MOHINDER
Authorized Official - Middle Name:
Authorized Official - Last Name:GUPTA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:718-464-5225
Mailing Address - Street 1:9033 SPRINGFIELD BLVD
Mailing Address - Street 2:
Mailing Address - City:QUEENS VILLAGE
Mailing Address - State:NY
Mailing Address - Zip Code:11428-1352
Mailing Address - Country:US
Mailing Address - Phone:718-464-5225
Mailing Address - Fax:
Practice Address - Street 1:9033 SPRINGFIELD BLVD
Practice Address - Street 2:
Practice Address - City:QUEENS VILLAGE
Practice Address - State:NY
Practice Address - Zip Code:11428-1352
Practice Address - Country:US
Practice Address - Phone:718-464-5225
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-21
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY108186173000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes173000000XOther Service ProvidersLegal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00190978Medicaid
NYE38788Medicare UPIN
NY00190978Medicaid
NY296171Medicare ID - Type Unspecified