Provider Demographics
NPI:1063426542
Name:GUPTA, SUMIT (PT)
Entity type:Individual
Prefix:
First Name:SUMIT
Middle Name:
Last Name:GUPTA
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5409 GATEWAY CENTRE DR
Mailing Address - Street 2:STE B
Mailing Address - City:FLINT
Mailing Address - State:MI
Mailing Address - Zip Code:48507-3992
Mailing Address - Country:US
Mailing Address - Phone:810-424-3201
Mailing Address - Fax:810-424-3202
Practice Address - Street 1:5409 GATEWAY CENTRE DR
Practice Address - Street 2:STE B
Practice Address - City:FLINT
Practice Address - State:MI
Practice Address - Zip Code:48507-3992
Practice Address - Country:US
Practice Address - Phone:810-424-3201
Practice Address - Fax:810-424-3202
Is Sole Proprietor?:No
Enumeration Date:2006-07-28
Last Update Date:2012-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MISG005488225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0P18660001Medicare ID - Type Unspecified