Provider Demographics
NPI:1386920650
Name:GUPTA, GUNJAN (RPT)
Entity type:Individual
Prefix:
First Name:GUNJAN
Middle Name:
Last Name:GUPTA
Suffix:
Gender:M
Credentials:RPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:555 S MISSION ST
Mailing Address - Street 2:
Mailing Address - City:MT PLEASANT
Mailing Address - State:MI
Mailing Address - Zip Code:48858-2846
Mailing Address - Country:US
Mailing Address - Phone:989-772-7755
Mailing Address - Fax:989-772-7750
Practice Address - Street 1:555 S MISSION ST
Practice Address - Street 2:
Practice Address - City:MT PLEASANT
Practice Address - State:MI
Practice Address - Zip Code:48858-2846
Practice Address - Country:US
Practice Address - Phone:989-772-7755
Practice Address - Fax:989-772-7750
Is Sole Proprietor?:No
Enumeration Date:2011-10-31
Last Update Date:2011-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5501014666225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI5501014666OtherSTATE OF MICHIGAN