MEDICARE: PRIYA GUPTA M.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	390200000X	Student in an Organized Health Care Education/Training Program
2	207W00000X	Ophthalmology Physician	R-8522	IA

General Provider Information

NPI Number	:	1366604787
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	PRIYA GUPTA M.D.

Provider Business Mailing Address
First Line	:	704 WESTSIDE DR
Second Line	:
City	:	IOWA CITY
State	:	IA
Zip	:	52246-4369
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	704 WESTSIDE DR
Second Line	:
City	:	IOWA CITY
State	:	IA
Zip	:	52246-4369
Country	:	US
Telephone Number	:	319-356-1616
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/26/2008
Last Update Date	:	06/01/2011

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