Provider Demographics
NPI:1881960383
Name:MANMOHAN GUPTA M.D., P.C.
Entity type:Organization
Organization Name:MANMOHAN GUPTA M.D., P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MANMOHAN
Authorized Official - Middle Name:
Authorized Official - Last Name:GUPTA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:478-741-4588
Mailing Address - Street 1:P.O. BOX 13026
Mailing Address - Street 2:
Mailing Address - City:MACON
Mailing Address - State:GA
Mailing Address - Zip Code:31208-3026
Mailing Address - Country:US
Mailing Address - Phone:478-741-4588
Mailing Address - Fax:478-741-4589
Practice Address - Street 1:770 PINE ST.
Practice Address - Street 2:SUITE 440
Practice Address - City:MACON
Practice Address - State:GA
Practice Address - Zip Code:31201-7599
Practice Address - Country:US
Practice Address - Phone:478-741-4588
Practice Address - Fax:478-741-4589
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-03-29
Last Update Date:2012-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA023976207RR0500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RR0500XAllopathic & Osteopathic PhysiciansInternal MedicineRheumatologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA00249796-AMedicaid
GA040036Medicare UPIN