Basic Information
Provider Information | |||||||||
NPI: | 1003896523 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | GUPTA | ||||||||
FirstName: | ADARSH | ||||||||
MiddleName: | K | ||||||||
NamePrefix: | DR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | D.O. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 532 OLD MARLTON PIKE W | ||||||||
Address2: | #529 | ||||||||
City: | MARLTON | ||||||||
State: | NJ | ||||||||
PostalCode: | 08053 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8564735695 | ||||||||
FaxNumber: | 8564974122 | ||||||||
Practice Location | |||||||||
Address1: | 42 LAUREL RD E | ||||||||
Address2: | UDP #2100 | ||||||||
City: | STRATFORD | ||||||||
State: | NJ | ||||||||
PostalCode: | 080841354 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8565667020 | ||||||||
FaxNumber: | 8565666188 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 01/19/2006 | ||||||||
LastUpdateDate: | 07/26/2021 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 07/26/2021 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 25MB07327000 | NJ | Y |   | Allopathic & Osteopathic Physicians | Family Medicine |   |
ID Information
ID | Type | State | Issuer | Description | 0001546 | 05 | NJ |   | MEDICAID |