Basic Information
| Provider Information | |||||||||
| NPI: | 1578974226 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | GUPTA | ||||||||
| FirstName: | SUPAKSH | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1959 NE PACIFIC ST RM BB-527 | ||||||||
| Address2: | BOX 356421 | ||||||||
| City: | SEATTLE | ||||||||
| State: | WA | ||||||||
| PostalCode: | 981956421 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2065433605 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1959 NE PACIFIC ST RM BB-527 | ||||||||
| Address2: | BOX 356421 | ||||||||
| City: | SEATTLE | ||||||||
| State: | WA | ||||||||
| PostalCode: | 981956421 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2065433605 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 05/15/2014 | ||||||||
| LastUpdateDate: | 07/25/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 07/25/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RP1001X | MD60953430 | WA | N | Allopathic & Osteopathic Physicians | Internal Medicine | Pulmonary Disease | 207RC0200X | MD60953430 | WA | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Critical Care Medicine |
ID Information
| ID | Type | State | Issuer | Description | 1578974226 | 05 | WA | MEDICAID |