Provider Demographics
NPI:1194888743
Name:GUPTA, DEEPAK (OD)
Entity type:Individual
Prefix:DR
First Name:DEEPAK
Middle Name:
Last Name:GUPTA
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:680 BOSTON POST RD # 5
Mailing Address - Street 2:SUITE 5
Mailing Address - City:MILFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06460-2684
Mailing Address - Country:US
Mailing Address - Phone:203-889-8578
Mailing Address - Fax:203-283-5226
Practice Address - Street 1:680 BOSTON POST RD
Practice Address - Street 2:UNIT 5
Practice Address - City:MILFORD
Practice Address - State:CT
Practice Address - Zip Code:06460-2684
Practice Address - Country:US
Practice Address - Phone:203-888-8578
Practice Address - Fax:203-283-5226
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-18
Last Update Date:2014-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT002532152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT410001041Medicare ID - Type Unspecified
CTU88520Medicare UPIN