Provider Demographics
NPI:1104947662
Name:GUPTA, PRIYADARSHAN (MD)
Entity type:Individual
Prefix:DR
First Name:PRIYADARSHAN
Middle Name:
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 1:237 E 28TH ST APT 5B
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10016-8593
Mailing Address - Country:US
Mailing Address - Phone:917-579-2284
Mailing Address - Fax:
Practice Address - Street 1:575 N RIVER ST
Practice Address - Street 2:
Practice Address - City:WILKES BARRE
Practice Address - State:PA
Practice Address - Zip Code:18764-4550
Practice Address - Country:US
Practice Address - Phone:570-552-4450
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-04-03
Last Update Date:2020-09-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC37739207R00000X
DCMD036500207R00000X
MDD0065591207R00000X
MI4301502925207R00000X, 208M00000X
NY237649208M00000X
PAMD471232208M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208M00000XAllopathic & Osteopathic PhysiciansHospitalist
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCSC5714F694Medicare PIN