Provider Demographics
NPI:1194977066
Name:AMITABH GUPTA MD PA
Entity type:Organization
Organization Name:AMITABH GUPTA MD PA
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:AMITABH
Authorized Official - Middle Name:P
Authorized Official - Last Name:GUPTA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:727-526-8000
Mailing Address - Street 1:5800 49TH ST N
Mailing Address - Street 2:SUITE S 205
Mailing Address - City:ST PETERSBURG
Mailing Address - State:FL
Mailing Address - Zip Code:33709-2146
Mailing Address - Country:US
Mailing Address - Phone:727-526-8000
Mailing Address - Fax:
Practice Address - Street 1:7895 SEMINOLE BLVD
Practice Address - Street 2:SUITE# 101
Practice Address - City:SEMINOLE
Practice Address - State:FL
Practice Address - Zip Code:33772-4891
Practice Address - Country:US
Practice Address - Phone:727-526-8000
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-10-22
Last Update Date:2011-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME85225208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL17034OtherBLUE CROSS BLUE SHIELD
FL299916OtherAVMED
FL304583OtherWELLCARE
FL2744716Medicaid
FL7966328OtherAETNA
FL6148200002Medicare NSC
FL17034OtherBLUE CROSS BLUE SHIELD
FLK8944Medicare PIN