Basic Information
| Provider Information | |||||||||
| NPI: | 1881652956 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | GUPTA | ||||||||
| FirstName: | SUBHASH | ||||||||
| MiddleName: | C | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 601 E. SAMPLE ROAD | ||||||||
| Address2: | SUITE 105 | ||||||||
| City: | POMPANO BEACH | ||||||||
| State: | FL | ||||||||
| PostalCode: | 33064 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9543442522 | ||||||||
| FaxNumber: | 9543449189 | ||||||||
| Practice Location | |||||||||
| Address1: | 601 E SAMPLE ROAD | ||||||||
| Address2: | SUITE 105 | ||||||||
| City: | POMPANO BEACH | ||||||||
| State: | FL | ||||||||
| PostalCode: | 33064 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9549431133 | ||||||||
| FaxNumber: | 9547836845 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/01/2006 | ||||||||
| LastUpdateDate: | 05/16/2012 | ||||||||
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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 | 207RG0100X | ME43566 | FL | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Gastroenterology |
ID Information
| ID | Type | State | Issuer | Description | 042423400 | 05 | FL | MEDICAID |