Provider Demographics
NPI:1750588943
Name:GUPTA, ANIRBAN (MD)
Entity type:Individual
Prefix:
First Name:ANIRBAN
Middle Name:
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:PO BOX 25608
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84125-0608
Mailing Address - Country:US
Mailing Address - Phone:206-320-4476
Mailing Address - Fax:206-568-7043
Practice Address - Street 1:1124 COLUMBIA ST STE 400
Practice Address - Street 2:
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98104-2053
Practice Address - Country:US
Practice Address - Phone:206-215-2090
Practice Address - Fax:206-215-3099
Is Sole Proprietor?:No
Enumeration Date:2007-06-29
Last Update Date:2022-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD60624891208600000X
OH35121672208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0087216Medicaid
WV3810026213Medicaid
WA1750588943Medicaid
OHH222170Medicare PIN
OHP01259808OtherRAILROAD MEDICARE - MHCPI