Provider Demographics
NPI:1750538609
Name:GUPTA, VIKRAM (MD)
Entity type:Individual
Prefix:
First Name:VIKRAM
Middle Name:
Last Name:GUPTA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 3399
Mailing Address - Street 2:
Mailing Address - City:WAYNE
Mailing Address - State:NJ
Mailing Address - Zip Code:07474-3399
Mailing Address - Country:US
Mailing Address - Phone:973-330-6765
Mailing Address - Fax:973-939-8489
Practice Address - Street 1:246 CLIFTON AVE STE 4
Practice Address - Street 2:
Practice Address - City:CLIFTON
Practice Address - State:NJ
Practice Address - Zip Code:07011-1953
Practice Address - Country:US
Practice Address - Phone:973-330-6765
Practice Address - Fax:973-939-8489
Is Sole Proprietor?:Yes
Enumeration Date:2008-08-22
Last Update Date:2012-10-02
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NJ25MA08471700207Q00000X, 208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice