1386677250 NPI number — DR. PREM P GUPTA M.D.

Table of content: DR. PREM P GUPTA M.D. (NPI 1386677250)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1386677250 NPI number — DR. PREM P GUPTA M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
GUPTA
Provider First Name:
PREM
Provider Middle Name:
P
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:
1386677250
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
05/30/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
12398 FM 423 STE 600
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
FRISCO
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
75033-0158
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
214-494-4622
Provider Business Mailing Address Fax Number:
214-494-4609

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
12398 FM 423 STE 600
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
FRISCO
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
75033-0158
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
214-494-4622
Provider Business Practice Location Address Fax Number:
214-494-4609
Provider Enumeration Date:
07/07/2006

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: 208000000X , with the licence number:  F7772 , 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: 4403201 . This is a "AETNA ID" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: 114191103 . This is a "FIRSTCARE HMO" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: 101054 . This is a "SUPERIOR HEALTHPLAN" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: 8H3960 . This is a "BCBS TX" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: 133070608 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".
  • Identifier: 155931202 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".




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