Provider Demographics
NPI:1215974225
Name:GUPTA, AJAY (MD)
Entity type:Individual
Prefix:DR
First Name:AJAY
Middle Name:
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 1:717 SOMERSET ST
Mailing Address - Street 2:
Mailing Address - City:FRANKLIN LAKES
Mailing Address - State:NJ
Mailing Address - Zip Code:07417-1036
Mailing Address - Country:US
Mailing Address - Phone:973-595-5345
Mailing Address - Fax:973-595-5069
Practice Address - Street 1:2 BRIGHTON RD STE 400
Practice Address - Street 2:
Practice Address - City:CLIFTON
Practice Address - State:NJ
Practice Address - Zip Code:07012-1670
Practice Address - Country:US
Practice Address - Phone:862-249-4904
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-31
Last Update Date:2024-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJMA42677207RC0000X
NJ25MA04267700207RI0011X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RI0011XAllopathic & Osteopathic PhysiciansInternal MedicineInterventional CardiologyGroup - Multi-Specialty
No207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ3855708Medicaid
NJC56936Medicare UPIN
NJ536641Medicare ID - Type Unspecified