Healthcare Provider Details

I. General information

NPI: 1376110585
Provider Name (Legal Business Name): SUNIL GUPTA MD LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/07/2021
Last Update Date: 06/07/2021
Certification Date: 06/07/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1299 INDUSTRIAL DR
CRESTVIEW FL
32539-8946
US

IV. Provider business mailing address

5150 N DAVIS HWY
PENSACOLA FL
32503-2030
US

V. Phone/Fax

Practice location:
  • Phone: 850-634-4342
  • Fax: 850-634-4353
Mailing address:
  • Phone: 850-476-6759
  • Fax: 850-484-5222

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207W00000X
TaxonomyOphthalmology Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207WX0107X
TaxonomyRetina Specialist (Ophthalmology) Physician
License Number
License Number State

VIII. Authorized Official

Name: SUNIL GUPTA
Title or Position: MANAGING PARTNER
Credential: MD
Phone: 850-476-6759