Basic Information
| Provider Information | |||||||||
| NPI: | 1609894898 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GUPTA | ||||||||
| FirstName: | ARCHANA | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | PO BOX 640 | ||||||||
| Address2: | |||||||||
| City: | HOLLYWOOD | ||||||||
| State: | MD | ||||||||
| PostalCode: | 206360640 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3013737318 | ||||||||
| FaxNumber: | 3013736900 | ||||||||
| Practice Location | |||||||||
| Address1: | 22590 SHADY CT | ||||||||
| Address2: | |||||||||
| City: | CALIFORNIA | ||||||||
| State: | MD | ||||||||
| PostalCode: | 206195009 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3013737900 | ||||||||
| FaxNumber: | 3013736900 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/17/2006 | ||||||||
| LastUpdateDate: | 09/13/2021 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 09/13/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207QA0000X | D0056261 | MD | N | Allopathic & Osteopathic Physicians | Family Medicine | Adolescent Medicine | 207Q00000X | S0056261 | MD | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 080160592 | 01 | MD | MEDICARE RAILROAD | OTHER | 291106000 | 05 | MD | MEDICAID |