Basic Information
| Provider Information | |||||||||
| NPI: | 1558383331 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | GUPTA | ||||||||
| FirstName: | SURESH | ||||||||
| MiddleName: | KUMAR | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4567 CROSSROADS PARK DRIVE | ||||||||
| Address2: | |||||||||
| City: | LIVERPOOL | ||||||||
| State: | NY | ||||||||
| PostalCode: | 130883589 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3154349309 | ||||||||
| FaxNumber: | 3154540136 | ||||||||
| Practice Location | |||||||||
| Address1: | 300 CENTRAL AVE | ||||||||
| Address2: | |||||||||
| City: | EAST ORANGE | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 070182819 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9732664444 | ||||||||
| FaxNumber: | 9732662932 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/24/2006 | ||||||||
| LastUpdateDate: | 02/10/2009 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207ZP0102X | 217303-1 | NY | N | Allopathic & Osteopathic Physicians | Pathology | Anatomic Pathology & Clinical Pathology | 207ZP0102X | 25MA04299600 | NJ | Y | Allopathic & Osteopathic Physicians | Pathology | Anatomic Pathology & Clinical Pathology |
ID Information
| ID | Type | State | Issuer | Description | 91082984D | 05 | NJ | MEDICAID |