Provider Demographics
NPI:1124311816
Name:GUPTA, ADITI (DO)
Entity type:Individual
Prefix:
First Name:ADITI
Middle Name:
Last Name:GUPTA
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6701 FANNIN ST
Mailing Address - Street 2:SUITE CCC1540
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77030-2608
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:8080 N STADIUM DR
Practice Address - Street 2:SUITE 250
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77054-1829
Practice Address - Country:US
Practice Address - Phone:713-303-5316
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-05-27
Last Update Date:2012-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXP2660208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX301069601Medicaid
301069602OtherCSHCN