Basic Information
| Provider Information | |||||||||
| NPI: | 1376645002 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | GUPTA | ||||||||
| FirstName: | SURESH | ||||||||
| MiddleName: | C | ||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 7330 SAN PEDRO AVE | ||||||||
| Address2: | STE 540 | ||||||||
| City: | SAN ANTONIO | ||||||||
| State: | TX | ||||||||
| PostalCode: | 782166250 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2103447287 | ||||||||
| FaxNumber: | 2103442649 | ||||||||
| Practice Location | |||||||||
| Address1: | 1510 S STATE RD | ||||||||
| Address2: | SUITE A | ||||||||
| City: | DAVISON | ||||||||
| State: | MI | ||||||||
| PostalCode: | 484231965 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8106530899 | ||||||||
| FaxNumber: | 8106534144 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/02/2006 | ||||||||
| LastUpdateDate: | 05/02/2018 | ||||||||
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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 | P4761 | TX | Y | Allopathic & Osteopathic Physicians | Internal Medicine | 207R00000X | 4301037942 | MI | N | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 3235996 | 05 | MI | MEDICAID |