Provider Demographics
NPI:1104112481
Name:GUPTA, MONIKA (PT)
Entity type:Individual
Prefix:
First Name:MONIKA
Middle Name:
Last Name:GUPTA
Suffix:
Gender:F
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:PO BOX 3497
Mailing Address - Street 2:
Mailing Address - City:STURTEVANT
Mailing Address - State:WI
Mailing Address - Zip Code:53177-0300
Mailing Address - Country:US
Mailing Address - Phone:888-201-1040
Mailing Address - Fax:866-245-8064
Practice Address - Street 1:841 S SAGINAW RD
Practice Address - Street 2:
Practice Address - City:MIDLAND
Practice Address - State:MI
Practice Address - Zip Code:48640-4664
Practice Address - Country:US
Practice Address - Phone:866-625-3570
Practice Address - Fax:866-245-8064
Is Sole Proprietor?:No
Enumeration Date:2011-06-24
Last Update Date:2011-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5501014860225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
N75070015Medicare PIN