Healthcare Provider Details

I. General information

NPI: 1558924183
Provider Name (Legal Business Name): SMRITI GUPTA MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/18/2019
Last Update Date: 10/21/2024
Certification Date: 10/18/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3311 N 44TH ST
PHOENIX AZ
85018-6461
US

IV. Provider business mailing address

2500 W UTOPIA RD STE 100
PHOENIX AZ
85027-4172
US

V. Phone/Fax

Practice location:
  • Phone: 480-882-7360
  • Fax: 480-882-5866
Mailing address:
  • Phone: 623-683-4462
  • Fax: 623-683-4963

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number35.145887
License Number StateOH
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number73428
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: