Provider Demographics
NPI:1154411197
Name:GUPTA, SURESH C (MD)
Entity type:Individual
Prefix:DR
First Name:SURESH
Middle Name:C
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 1:3503 PERRY ST
Mailing Address - Street 2:
Mailing Address - City:MOUNT RAINIER
Mailing Address - State:MD
Mailing Address - Zip Code:20712
Mailing Address - Country:US
Mailing Address - Phone:301-864-1133
Mailing Address - Fax:301-864-2155
Practice Address - Street 1:3503 PERRY ST
Practice Address - Street 2:
Practice Address - City:MOUNT RAINER
Practice Address - State:MD
Practice Address - Zip Code:20712
Practice Address - Country:US
Practice Address - Phone:301-864-1133
Practice Address - Fax:301-864-2155
Is Sole Proprietor?:No
Enumeration Date:2006-10-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD14876207RP1001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD0177201400Medicaid
MD0177201400Medicaid
161298Medicare ID - Type Unspecified