1619089000 NPI number — DR. GHANSHYAM GUPTA M.D

Table of content: DR. GHANSHYAM GUPTA M.D (NPI 1619089000)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1619089000 NPI number — DR. GHANSHYAM GUPTA M.D

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
GUPTA
Provider First Name:
GHANSHYAM
Provider Middle Name:
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
M.D
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
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:
1619089000
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
02/23/2017
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 60410
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
POTOMAC
Provider Business Mailing Address State Name:
MD
Provider Business Mailing Address Postal Code:
20859-0410
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
301-838-4224
Provider Business Mailing Address Fax Number:
301-838-4244

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
10110 MOLECULAR DR STE 111
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ROCKVILLE
Provider Business Practice Location Address State Name:
MD
Provider Business Practice Location Address Postal Code:
20850-7538
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
301-838-4224
Provider Business Practice Location Address Fax Number:
301-838-4244
Provider Enumeration Date:
08/31/2006

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207RG0100X , with the licence number:  D0046398 , registered in the state of MD ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 026309900 , issued by the state of ( DC ) . This identifiers is of the category "MEDICAID".
  • Identifier: 53363801 . This is a "BC.BS." identifier , issued by the state of ( MD ) . This identifiers is of the category "OTHER".
  • Identifier: 407274000 , issued by the state of ( MD ) . This identifiers is of the category "MEDICAID".
  • Identifier: B0750001 . This is a "BC.BS." identifier , issued by the state of ( DC ) . This identifiers is of the category "OTHER".