1639113996 NPI number — NARESH K GUPTA MD

Table of content: NARESH K GUPTA MD (NPI 1639113996)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1639113996 NPI number — NARESH K GUPTA MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
GUPTA
Provider First Name:
NARESH
Provider Middle Name:
K
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MD
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:
1639113996
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/04/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
6308 DAKOTA DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
PLANO
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
75024-6011
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
972-839-0364
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
9040 JACKSON AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
TACOMA
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
98431-1100
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
253-968-2504
Provider Business Practice Location Address Fax Number:
253-968-1136
Provider Enumeration Date:
06/16/2006

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: 207RH0003X , with the licence number:  K4073 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 097088103 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".
  • Identifier: 0083EZ . This is a "BC/BS" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".




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