Provider Demographics
NPI:1083788400
Name:GUPTA, JAGDISH K (MD)
Entity type:Individual
Prefix:
First Name:JAGDISH
Middle Name:K
Last Name:GUPTA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15 HAMILTON DR
Mailing Address - Street 2:
Mailing Address - City:ROSLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11576-3103
Mailing Address - Country:US
Mailing Address - Phone:516-746-2266
Mailing Address - Fax:718-638-4033
Practice Address - Street 1:28 8TH AVE
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11217-3919
Practice Address - Country:US
Practice Address - Phone:718-638-3150
Practice Address - Fax:718-638-4033
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY123886-1207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYJG311401Medicare ID - Type Unspecified
NYB12737Medicare UPIN