Provider Demographics
NPI:1912926510
Name:GUPTA, SAURABH (MD)
Entity Type:Individual
Prefix:DR
First Name:SAURABH
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 1:610 E 12 MILE RD
Mailing Address - Street 2:STE B
Mailing Address - City:MADISON HEIGHTS
Mailing Address - State:MI
Mailing Address - Zip Code:48071-2567
Mailing Address - Country:US
Mailing Address - Phone:248-850-3116
Mailing Address - Fax:248-850-3119
Practice Address - Street 1:610 E 12 MILE RD
Practice Address - Street 2:STE B
Practice Address - City:MADISON HEIGHTS
Practice Address - State:MI
Practice Address - Zip Code:48071-2567
Practice Address - Country:US
Practice Address - Phone:248-850-3116
Practice Address - Fax:248-850-3119
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-18
Last Update Date:2014-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301064922207R00000X, 207RG0300X, 207RH0002X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No207RG0300XAllopathic & Osteopathic PhysiciansInternal MedicineGeriatric Medicine
No207RH0002XAllopathic & Osteopathic PhysiciansInternal MedicineHospice and Palliative Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4828460Medicaid
MIP00285735OtherRAILROAD MEDICARE
MI4841640Medicaid
MIP00285735OtherRAILROAD MEDICARE
MI4828460Medicaid