Basic Information
| Provider Information | |||||||||
| NPI: | 1487662003 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GUPTA | ||||||||
| FirstName: | SUMIT | ||||||||
| MiddleName: | KUMAR | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 6035 FAIRVIEW RD | ||||||||
| Address2: | |||||||||
| City: | CHARLOTTE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 282103256 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7042953000 | ||||||||
| FaxNumber: | 7042953506 | ||||||||
| Practice Location | |||||||||
| Address1: | 2325 W ARBORS DR | ||||||||
| Address2: | SUITE 201 | ||||||||
| City: | CHARLOTTE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 282622663 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7042953500 | ||||||||
| FaxNumber: | 7042953506 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/03/2006 | ||||||||
| LastUpdateDate: | 05/03/2018 | ||||||||
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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 | 207W00000X | SG075835 | MI | N | Allopathic & Osteopathic Physicians | Ophthalmology | 207W00000X | 2008-01681 | NC | Y | Allopathic & Osteopathic Physicians | Ophthalmology |
ID Information
| ID | Type | State | Issuer | Description | 1502C | 01 | NC | BCBSNC | OTHER | 180G410170 | 01 | MI | BCBS GROUP | OTHER | 20096148 | 01 | SC | SELECT HEALTH OF SC | OTHER | 2687 | 01 | NC | EVOLUTIONS HEALTHCARE | OTHER | 5910409 | 05 | NC | MEDICAID | 7719573 | 01 | NC | AETNA | OTHER | N01682 | 05 | SC | MEDICAID | 104779114 | 05 | MI | MEDICAID | 89695 | 01 | SC | CHCARES OF SC | OTHER | 01224936 | 01 | SC | AMERIGROUP | OTHER | P00667584 | 01 | SC | MEDICARE RAILROAD | OTHER | SG075835 | 01 | MI | MED LICENSE | OTHER | 000000291982 | 01 | SC | UNISON HEALTH PLAN OF SC | OTHER | 773424 | 01 | SC | WELLCARE | OTHER |