Provider Demographics
NPI:1912977646
Name:GUPTA, MITA (OD)
Entity Type:Individual
Prefix:DR
First Name:MITA
Middle Name:
Last Name:GUPTA
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13109 OAT CT
Mailing Address - Street 2:
Mailing Address - City:WOODBRIDGE
Mailing Address - State:VA
Mailing Address - Zip Code:22193-7010
Mailing Address - Country:US
Mailing Address - Phone:804-929-6829
Mailing Address - Fax:
Practice Address - Street 1:8912 CENTREVILLE RD
Practice Address - Street 2:
Practice Address - City:MANASSAS
Practice Address - State:VA
Practice Address - Zip Code:20110-8455
Practice Address - Country:US
Practice Address - Phone:703-361-6151
Practice Address - Fax:703-361-1750
Is Sole Proprietor?:Yes
Enumeration Date:2006-01-25
Last Update Date:2009-12-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0618001643152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA1912977646Medicaid