Provider Demographics
NPI:1881612133
Name:GUPTA, VIVEK KUMAR (MD)
Entity type:Individual
Prefix:DR
First Name:VIVEK
Middle Name:KUMAR
Last Name:GUPTA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:6002 PROFESSIONAL PARKWAY
Mailing Address - Street 2:SUITE 100
Mailing Address - City:DOUGLASVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30134
Mailing Address - Country:US
Mailing Address - Phone:770-949-4200
Mailing Address - Fax:770-949-5553
Practice Address - Street 1:6002 PROFESSIONAL PARKWAY
Practice Address - Street 2:SUITE 100
Practice Address - City:DOUGLASVILLE
Practice Address - State:GA
Practice Address - Zip Code:30134
Practice Address - Country:US
Practice Address - Phone:770-949-4200
Practice Address - Fax:770-949-5553
Is Sole Proprietor?:No
Enumeration Date:2006-07-17
Last Update Date:2011-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA052734207Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngology
Provider Identifiers
StateIdentifier IDID TypeIssuer
P00107542OtherRAILROAD MEDICARE
GA003379537AMedicaid
072044OtherBLUE
7157520OtherAETNA PPO
GA003379537BMedicaid
323384OtherWELLCARE
5418507001OtherCIGNA
7157520OtherAETNA HMO
P00107542OtherRAILROAD MEDICARE
323384OtherWELLCARE