Provider Demographics
NPI:1750390894
Name:GUPTA, MITA (MD)
Entity type:Individual
Prefix:
First Name:MITA
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 1:433 W MAIN ST
Mailing Address - Street 2:
Mailing Address - City:HYANNIS
Mailing Address - State:MA
Mailing Address - Zip Code:02601-3644
Mailing Address - Country:US
Mailing Address - Phone:508-778-4777
Mailing Address - Fax:
Practice Address - Street 1:EMERALD PHYSICIANS
Practice Address - Street 2:433 WEST MAIN STREET
Practice Address - City:HYANNIS
Practice Address - State:MA
Practice Address - Zip Code:02601
Practice Address - Country:US
Practice Address - Phone:508-778-4777
Practice Address - Fax:508-778-4777
Is Sole Proprietor?:No
Enumeration Date:2006-08-07
Last Update Date:2008-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA226951207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
491569OtherUSFHP
495144OtherTUFTS
J40748OtherBCBS
AA68865OtherPILGRIM
7909864OtherAETNA
AA68865OtherPILGRIM
I161332Medicare UPIN