Basic Information
Provider Information | |||||||||
NPI: | 1033670237 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | GUPTA | ||||||||
FirstName: | NIKHIL | ||||||||
MiddleName: | R | ||||||||
NamePrefix: | DR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | MD | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 800 CLEMATIS ST STE 5-531 | ||||||||
Address2: |   | ||||||||
City: | WEST PALM BEACH | ||||||||
State: | FL | ||||||||
PostalCode: | 334015107 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5616714036 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 1250 SOUTHWINDS DR | ||||||||
Address2: |   | ||||||||
City: | LANTANA | ||||||||
State: | FL | ||||||||
PostalCode: | 334621459 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5615476800 | ||||||||
FaxNumber: | 5615476865 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 03/29/2019 | ||||||||
LastUpdateDate: | 03/21/2022 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | Y | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 03/21/2022 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 390200000X |   |   | N |   | Student, Health Care | Student in an Organized Health Care Education/Training Program |   | 2083P0901X | TRN32423 | FL | Y |   | Allopathic & Osteopathic Physicians | Preventive Medicine | Public Health & General Preventive Medicine |
No ID Information.