Provider Demographics
NPI:1811901309
Name:GUPTA, NEELUM (MD)
Entity type:Individual
Prefix:
First Name:NEELUM
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 1:1695 W 12 MILE RD
Mailing Address - Street 2:SUITE 200
Mailing Address - City:BERKLEY
Mailing Address - State:MI
Mailing Address - Zip Code:48072-2182
Mailing Address - Country:US
Mailing Address - Phone:248-548-9090
Mailing Address - Fax:248-548-8462
Practice Address - Street 1:1695 W 12 MILE RD
Practice Address - Street 2:SUITE 200
Practice Address - City:BERKLEY
Practice Address - State:MI
Practice Address - Zip Code:48072-2182
Practice Address - Country:US
Practice Address - Phone:248-548-9090
Practice Address - Fax:248-548-8462
Is Sole Proprietor?:No
Enumeration Date:2006-07-28
Last Update Date:2016-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301066816207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1811901309Medicaid
MI0F37128OtherBCBSM
MI4715799Medicaid
MI1811901309Medicaid
MIH64909Medicare UPIN
MI0F37128OtherBCBSM