Provider Demographics
NPI:1285788463
Name:GUPTA, ASHOK (MD)
Entity type:Individual
Prefix:DR
First Name:ASHOK
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:PO BOX 645
Mailing Address - Street 2:
Mailing Address - City:KEEGO HARBOR
Mailing Address - State:MI
Mailing Address - Zip Code:48320-0645
Mailing Address - Country:US
Mailing Address - Phone:248-681-6577
Mailing Address - Fax:248-732-7136
Practice Address - Street 1:2111 ORCHARD LAKE RD
Practice Address - Street 2:
Practice Address - City:SYLVAN LAKE
Practice Address - State:MI
Practice Address - Zip Code:48320-1785
Practice Address - Country:US
Practice Address - Phone:248-681-6577
Practice Address - Fax:248-732-7136
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-23
Last Update Date:2013-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301042770207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIOP20810Medicare PIN
MIB44353Medicare UPIN