Provider Demographics
NPI:1952474504
Name:GUPTA, INDRANIL (MD)
Entity Type:Individual
Prefix:
First Name:INDRANIL
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 1:1033 ROSEDALE ROAD
Mailing Address - Street 2:
Mailing Address - City:NORTH WOODMERE
Mailing Address - State:NY
Mailing Address - Zip Code:11581
Mailing Address - Country:US
Mailing Address - Phone:516-837-9113
Mailing Address - Fax:516-837-9113
Practice Address - Street 1:3187 STEINWAY ST
Practice Address - Street 2:SUITE 6
Practice Address - City:ASTORIA
Practice Address - State:NY
Practice Address - Zip Code:11103-9816
Practice Address - Country:US
Practice Address - Phone:718-626-4881
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-15
Last Update Date:2011-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY206503208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01765282Medicaid
NY1Q3541Medicare ID - Type Unspecified
NY01765282Medicaid