Provider Demographics
NPI:1811105208
Name:GUPTA, SHAIFALI (MD)
Entity type:Individual
Prefix:
First Name:SHAIFALI
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 1:100 N ACADEMY AVE
Mailing Address - Street 2:
Mailing Address - City:DANVILLE
Mailing Address - State:PA
Mailing Address - Zip Code:17822-4903
Mailing Address - Country:US
Mailing Address - Phone:570-271-6144
Mailing Address - Fax:
Practice Address - Street 1:190 WELLES ST
Practice Address - Street 2:
Practice Address - City:KINGSTON
Practice Address - State:PA
Practice Address - Zip Code:18704-4968
Practice Address - Country:US
Practice Address - Phone:570-718-4140
Practice Address - Fax:570-718-4141
Is Sole Proprietor?:No
Enumeration Date:2007-05-18
Last Update Date:2020-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD437698208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA162121OtherMEDICARE