Healthcare Provider Details

I. General information

NPI: 1942244439
Provider Name (Legal Business Name): VIVEK GUPTA MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/15/2006
Last Update Date: 01/25/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2109 60TH ST W
BRADENTON FL
34209-5526
US

IV. Provider business mailing address

6610 TURNSTONE LN
LAKEWOOD RANCH FL
34202-8291
US

V. Phone/Fax

Practice location:
  • Phone: 941-315-1919
  • Fax:
Mailing address:
  • Phone: 941-315-1919
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2085N0904X
TaxonomyNuclear Radiology Physician
License NumberME94215
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: