Provider Demographics
NPI:1215097829
Name:GUPTA, PRADEEP K (MD)
Entity type:Individual
Prefix:
First Name:PRADEEP
Middle Name:K
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 1:1914 GABLES LN
Mailing Address - Street 2:
Mailing Address - City:VIENNA
Mailing Address - State:VA
Mailing Address - Zip Code:22182-6008
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1715 N GEORGE MASON DR
Practice Address - Street 2:SUITE 204
Practice Address - City:ARLINGTON
Practice Address - State:VA
Practice Address - Zip Code:22205-3609
Practice Address - Country:US
Practice Address - Phone:703-522-0751
Practice Address - Fax:703-528-4209
Is Sole Proprietor?:No
Enumeration Date:2006-12-12
Last Update Date:2012-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101044494207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA0101044494OtherSTATE LICENSE
F36436Medicare UPIN
085270R69Medicare PIN