Provider Demographics
NPI:1912990011
Name:GUPTA, TARSEM L (MD)
Entity Type:Individual
Prefix:
First Name:TARSEM
Middle Name:L
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 1:245 VILLAGE CENTER PKWY STE 100
Mailing Address - Street 2:
Mailing Address - City:STOCKBRIDGE
Mailing Address - State:GA
Mailing Address - Zip Code:30281-9096
Mailing Address - Country:US
Mailing Address - Phone:770-506-7171
Mailing Address - Fax:770-506-8406
Practice Address - Street 1:245 VILLAGE CENTER PKWY STE 100
Practice Address - Street 2:
Practice Address - City:STOCKBRIDGE
Practice Address - State:GA
Practice Address - Zip Code:30281-9096
Practice Address - Country:US
Practice Address - Phone:770-506-7171
Practice Address - Fax:770-506-8406
Is Sole Proprietor?:No
Enumeration Date:2005-08-24
Last Update Date:2019-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA028410207RP1001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000401178EMedicaid
GA300028737AMedicaid
GA592806OtherBCBS OF GEORGIA
GA000401178DMedicaid
GA000401178EMedicaid
GA592806OtherBCBS OF GEORGIA
GA300028737AMedicaid