Provider Demographics
NPI:1831274315
Name:GUPTA, SANJEEV (MD)
Entity type:Individual
Prefix:DR
First Name:SANJEEV
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 1:1515 BLONDELL AVE
Mailing Address - Street 2:SUITE 220
Mailing Address - City:BRONX
Mailing Address - State:NY
Mailing Address - Zip Code:10461-2601
Mailing Address - Country:US
Mailing Address - Phone:866-633-8255
Mailing Address - Fax:718-430-8975
Practice Address - Street 1:1515 BLONDELL AVE
Practice Address - Street 2:SUITE 220
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10461-2601
Practice Address - Country:US
Practice Address - Phone:866-633-8255
Practice Address - Fax:718-430-8975
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-25
Last Update Date:2012-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY174208207R00000X
NY17428207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY34F79Medicare ID - Type Unspecified
NYE87313Medicare UPIN