Basic Information
| Provider Information | |||||||||
| NPI: | 1740238906 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | GUPTA | ||||||||
| FirstName: | SANJAY | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 65 VIA FORESTA LANE | ||||||||
| Address2: | |||||||||
| City: | WILLIAMSVILLE | ||||||||
| State: | NY | ||||||||
| PostalCode: | 142211982 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7168956700 | ||||||||
| FaxNumber: | 7163324488 | ||||||||
| Practice Location | |||||||||
| Address1: | 1526 WALDEN AVENUE | ||||||||
| Address2: | SUITE 400 | ||||||||
| City: | CHEEKTOWAGA | ||||||||
| State: | NY | ||||||||
| PostalCode: | 142254985 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7168956700 | ||||||||
| FaxNumber: | 7163324488 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/04/2006 | ||||||||
| LastUpdateDate: | 10/24/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 10/24/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2084P0800X | 182506 | NY | Y | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Psychiatry |
ID Information
| ID | Type | State | Issuer | Description | 01570974 | 05 | NY | MEDICAID |