1588610075 NPI number — SUNIL GUPTA MD LLC

Table of content: (NPI 1588610075)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1588610075 NPI number — SUNIL GUPTA MD LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SUNIL GUPTA MD LLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
RETINA SPECIALTY INSTITUTE
Provider Other Organization Name Type Code:
3
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1588610075
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/31/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
5150 N DAVIS HWY
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
PENSACOLA
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
32503-2030
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
850-476-6759
Provider Business Mailing Address Fax Number:
850-484-5222

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
5150 N DAVIS HWY
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
PENSACOLA
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
32503-2030
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
850-476-6759
Provider Business Practice Location Address Fax Number:
850-484-5222
Provider Enumeration Date:
05/26/2006

Additional Information

Authorized Official

Authorized Official Last Name:
GUPTA
Authorized Official First Name:
SUNIL
Authorized Official Middle Name:
Authorized Official Title or Position:
MANAGING MEMBER
Authorized Official Telephone Number:
850-476-6759

Provider Taxonomy Codes

  • Taxonomy code: 207W00000X , with the licence number:  ME66379 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 529917080 , issued by the state of ( AL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 34843 . This is a "BLUE CROSS PROVIDER GROUP" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: 09016091 , issued by the state of ( MS ) . This identifiers is of the category "MEDICAID".
  • Identifier: 07331062 . This is a "MEDICAID" identifier , issued by the state of ( MS ) . This identifiers is of the category "OTHER".
  • Identifier: 267921300 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".




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