Provider Demographics
NPI:1831170224
Name:PREM K GUPTA MD PC
Entity type:Organization
Organization Name:PREM K GUPTA MD PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT OWNER
Authorized Official - Prefix:
Authorized Official - First Name:PREM
Authorized Official - Middle Name:K
Authorized Official - Last Name:GUPTA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:718-633-4244
Mailing Address - Street 1:4709 FORT HAMILTON PKWY
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11219-2927
Mailing Address - Country:US
Mailing Address - Phone:718-633-4244
Mailing Address - Fax:718-437-1556
Practice Address - Street 1:4709 FORT HAMILTON PKWY
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11219-2927
Practice Address - Country:US
Practice Address - Phone:718-633-4244
Practice Address - Fax:718-437-1556
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-11-11
Last Update Date:2007-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY108782207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular DiseaseGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00192549Medicaid
C07847Medicare UPIN
NY289631Medicare ID - Type Unspecified