Provider Demographics
NPI:1801895735
Name:GUPTA, MANOJ (DO)
Entity type:Individual
Prefix:DR
First Name:MANOJ
Middle Name:
Last Name:GUPTA
Suffix:
Gender:M
Credentials:DO
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 1070
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28201-1070
Mailing Address - Country:US
Mailing Address - Phone:800-476-8646
Mailing Address - Fax:919-382-3210
Practice Address - Street 1:1638 OWEN DR
Practice Address - Street 2:
Practice Address - City:FAYETTEVILLE
Practice Address - State:NC
Practice Address - Zip Code:28304-3424
Practice Address - Country:US
Practice Address - Phone:910-609-6439
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-07-21
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NCE0449OtherMEDCOST # DR. GUPTA
NC891376YMedicaid
NC891376YMedicaid
NC2034616AMedicare ID - Type UnspecifiedGROUP # 2336501
NCE0449OtherMEDCOST # DR. GUPTA