Basic Information
| Provider Information | |||||||||
| NPI: | 1790735181 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | GUPTA | ||||||||
| FirstName: | BHAVDEEP | ||||||||
| MiddleName: | K | ||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | MD, FACC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 7007 HARBOUR VIEW BLVD | ||||||||
| Address2: | SUITE 108 | ||||||||
| City: | SUFFOLK | ||||||||
| State: | VA | ||||||||
| PostalCode: | 234353657 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7572152784 | ||||||||
| FaxNumber: | 7572152728 | ||||||||
| Practice Location | |||||||||
| Address1: | 1030 HILLPOINT BLVD N | ||||||||
| Address2: | |||||||||
| City: | SUFFOLK | ||||||||
| State: | VA | ||||||||
| PostalCode: | 234348470 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7575390444 | ||||||||
| FaxNumber: | 7575394824 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/10/2006 | ||||||||
| LastUpdateDate: | 02/25/2015 | ||||||||
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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 | 174400000X | 0101051058 | VA | N | Other Service Providers | Specialist | 207RC0000X | 0101051058 | VA | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Cardiovascular Disease | 207UN0901X | 0101051058 | VA | N | Allopathic & Osteopathic Physicians | Nuclear Medicine | Nuclear Cardiology |
ID Information
| ID | Type | State | Issuer | Description | 006011977 | 05 | VA | MEDICAID |