Provider Demographics
NPI:1528117389
Name:GUPTA, MINI (MD)
Entity type:Individual
Prefix:DR
First Name:MINI
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 1:301 LIPPINCOTT DR STE 410
Mailing Address - Street 2:
Mailing Address - City:MARLTON
Mailing Address - State:NJ
Mailing Address - Zip Code:08053-4197
Mailing Address - Country:US
Mailing Address - Phone:856-355-0340
Mailing Address - Fax:856-355-0330
Practice Address - Street 1:216 HADDON AVE
Practice Address - Street 2:SUITE 100
Practice Address - City:HADDON TOWNSHIP
Practice Address - State:NJ
Practice Address - Zip Code:08108-2809
Practice Address - Country:US
Practice Address - Phone:856-854-6600
Practice Address - Fax:856-854-6610
Is Sole Proprietor?:No
Enumeration Date:2007-01-10
Last Update Date:2020-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA07795500207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ0091294Medicaid
NJ0091294Medicaid