Provider Demographics
NPI:1366414658
Name:GUPTA, SUSHMA (MD)
Entity type:Individual
Prefix:
First Name:SUSHMA
Middle Name:
Last Name:GUPTA
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:108 HIGHLAND PARK PLZ
Mailing Address - Street 2:SUITE 108
Mailing Address - City:COVINGTON
Mailing Address - State:LA
Mailing Address - Zip Code:70433-7116
Mailing Address - Country:US
Mailing Address - Phone:985-892-8660
Mailing Address - Fax:985-892-0908
Practice Address - Street 1:108 HIGHLAND PARK PLZ
Practice Address - Street 2:SUITE 108
Practice Address - City:COVINGTON
Practice Address - State:LA
Practice Address - Zip Code:70433-7116
Practice Address - Country:US
Practice Address - Phone:985-892-8660
Practice Address - Fax:985-892-0908
Is Sole Proprietor?:Yes
Enumeration Date:2006-02-02
Last Update Date:2011-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA012915174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1155667Medicaid
LAB60328Medicare UPIN
LA5J148Medicare ID - Type Unspecified