Basic Information
| Provider Information | |||||||||
| NPI: | 1932302924 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | GUPTA | ||||||||
| FirstName: | SANCHITA | ||||||||
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| Credential: | M.D., MPH | ||||||||
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| Mailing Information | |||||||||
| Address1: | 466 OLD HOOK RD | ||||||||
| Address2: | SUITE 1 | ||||||||
| City: | EMERSON | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 076301396 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2019678221 | ||||||||
| FaxNumber: | 2019670340 | ||||||||
| Practice Location | |||||||||
| Address1: | 190 DAYTON ST | ||||||||
| Address2: | SUITE 1 | ||||||||
| City: | RIDGEWOOD | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 074504422 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2016707800 | ||||||||
| FaxNumber: | 2016707720 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/07/2007 | ||||||||
| LastUpdateDate: | 06/02/2015 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 25MA09579800 | NJ | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 375312YXW7 | 01 | NJ | MEDICARE PTAN | OTHER |