Healthcare Provider Details

I. General information

NPI: 1902518939
Provider Name (Legal Business Name): ID DOC LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/21/2022
Last Update Date: 10/06/2023
Certification Date: 10/06/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

410 FOULK RD STE 105
WILMINGTON DE
19803-3835
US

IV. Provider business mailing address

8 PENNOCK DR
GARNET VALLEY PA
19060-1400
US

V. Phone/Fax

Practice location:
  • Phone: 302-295-9300
  • Fax: 302-384-7162
Mailing address:
  • Phone: 302-295-9300
  • Fax: 302-384-7162

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RI0200X
TaxonomyInfectious Disease Physician
License Number
License Number State

VIII. Authorized Official

Name: DR. MAYA GUPTA
Title or Position: OWNER
Credential: MD
Phone: 302-295-9300