Basic Information
| Provider Information | |||||||||
| NPI: | 1013113364 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | GUPTA | ||||||||
| FirstName: | NITIN | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1001 SUMMIT BLVD STE B | ||||||||
| Address2: | |||||||||
| City: | BROOKHAVEN | ||||||||
| State: | GA | ||||||||
| PostalCode: | 303196408 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7709891668 | ||||||||
| FaxNumber: | 6783881759 | ||||||||
| Practice Location | |||||||||
| Address1: | 980 JOHNSON FY RD NE STE 820 | ||||||||
| Address2: | |||||||||
| City: | ATLANTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 303421608 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4042529307 | ||||||||
| FaxNumber: | 4042525839 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/25/2007 | ||||||||
| LastUpdateDate: | 10/03/2018 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 22586 | MS | N | Allopathic & Osteopathic Physicians | Internal Medicine | 207RG0100X | 249386 | MA | N | Allopathic & Osteopathic Physicians | Internal Medicine | Gastroenterology | 207RG0100X | 22586 | MS | N | Allopathic & Osteopathic Physicians | Internal Medicine | Gastroenterology | 207RG0100X | 078939 | GA | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Gastroenterology |
ID Information
| ID | Type | State | Issuer | Description | 02959257 | 05 | MS | MEDICAID | P01402449 | 01 | MS | RR MEDICARE | OTHER | 003203822A | 05 | GA | MEDICAID |