Provider Demographics
NPI:1992080956
Name:GUPTA, SAURABH KUMAR
Entity type:Individual
Prefix:MR
First Name:SAURABH
Middle Name:KUMAR
Last Name:GUPTA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:333 FIRST STREET NORTH,
Mailing Address - Street 2:C/O STANI VELJACA, SUITE 200
Mailing Address - City:JACKSONVILLE BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32250
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2075 NW HIGHLAND AVE
Practice Address - Street 2:
Practice Address - City:GRANT PASS
Practice Address - State:OR
Practice Address - Zip Code:97526
Practice Address - Country:US
Practice Address - Phone:541-476-8891
Practice Address - Fax:541-476-2679
Is Sole Proprietor?:No
Enumeration Date:2011-10-20
Last Update Date:2011-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR284998225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist