Provider Demographics
NPI:1912467192
Name:GUPTA, DIKSHA
Entity Type:Individual
Prefix:
First Name:DIKSHA
Middle Name:
Last Name:GUPTA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9409 OLD BURKE LAKE RD # B
Mailing Address - Street 2:
Mailing Address - City:BURKE
Mailing Address - State:VA
Mailing Address - Zip Code:22015-3127
Mailing Address - Country:US
Mailing Address - Phone:703-978-4200
Mailing Address - Fax:
Practice Address - Street 1:9409 OLD BURKE LAKE RD # B
Practice Address - Street 2:
Practice Address - City:BURKE
Practice Address - State:VA
Practice Address - Zip Code:22015-3127
Practice Address - Country:US
Practice Address - Phone:703-978-4200
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-03-22
Last Update Date:2022-06-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0102207087207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine