Healthcare Provider Details

I. General information

NPI: 1548655681
Provider Name (Legal Business Name): MANIK KUMAR GUPTA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/06/2015
Last Update Date: 12/11/2025
Certification Date: 12/11/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2601 E ROOSEVELT ST
PHOENIX AZ
85008-4973
US

IV. Provider business mailing address

3800 WOODWARD AVE APT 704
DETROIT MI
48201-1980
US

V. Phone/Fax

Practice location:
  • Phone: 602-344-5011
  • Fax:
Mailing address:
  • Phone: 404-805-3042
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License Number63104
License Number StateAZ
# 2
Primary TaxonomyN
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License NumberCDR.0006114
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: