Basic Information
| Provider Information | |||||||||
| NPI: | 1417271420 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | GUPTA | ||||||||
| FirstName: | MANEESH | ||||||||
| MiddleName: | KUMAR | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2920 N CASCADE AVE | ||||||||
| Address2: | STE 300 | ||||||||
| City: | COLORADO SPRINGS | ||||||||
| State: | CO | ||||||||
| PostalCode: | 809076262 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7196361201 | ||||||||
| FaxNumber: | 7199550986 | ||||||||
| Practice Location | |||||||||
| Address1: | 2352 MEADOWS BLVD STE 300 | ||||||||
| Address2: | |||||||||
| City: | CASTLE ROCK | ||||||||
| State: | CO | ||||||||
| PostalCode: | 801098419 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7204553879 | ||||||||
| FaxNumber: | 7204553795 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/19/2010 | ||||||||
| LastUpdateDate: | 07/21/2022 | ||||||||
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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 | 390200000X | N | Student, Health Care | Student in an Organized Health Care Education/Training Program | 207RG0100X | 57969 | CO | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Gastroenterology | 207RG0100X | MD205242 | LA | N | Allopathic & Osteopathic Physicians | Internal Medicine | Gastroenterology |
ID Information
| ID | Type | State | Issuer | Description | 2106643 | 05 | LA | MEDICAID | 06189557 | 05 | MS | MEDICAID |