Provider Demographics
NPI:1720168164
Name:GUPTA, BALDEV K (MD)
Entity Type:Individual
Prefix:
First Name:BALDEV
Middle Name:K
Last Name:GUPTA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3700 WEST RD
Mailing Address - Street 2:
Mailing Address - City:TRENTON
Mailing Address - State:MI
Mailing Address - Zip Code:48183-2224
Mailing Address - Country:US
Mailing Address - Phone:734-676-5600
Mailing Address - Fax:734-676-5591
Practice Address - Street 1:3700 WEST RD
Practice Address - Street 2:
Practice Address - City:TRENTON
Practice Address - State:MI
Practice Address - Zip Code:48183-2224
Practice Address - Country:US
Practice Address - Phone:734-676-5600
Practice Address - Fax:734-676-5591
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301070829207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0829931OtherBLUECARE NETWORK
MI1108299311OtherBLUE CROSS BLUE SHIELD
MI7399359OtherAETNA
MI110243955OtherRAILROAD MEDICARE
MI4409445 10Medicaid
MI4684342OtherCIGNA HEALTHCARE
MI6U4023OtherHAP
MI1108299311OtherBLUE CROSS BLUE SHIELD
MI6U4023OtherHAP