Healthcare Provider Details

I. General information

NPI: 1467424382
Provider Name (Legal Business Name): SHAILESH K GUPTA MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/03/2006
Last Update Date: 03/27/2024
Certification Date: 03/27/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2001 W SAMPLE RD STE 320
DEERFIELD BEACH FL
33064-1346
US

IV. Provider business mailing address

2001 W SAMPLE RD STE 320
DEERFIELD BEACH FL
33064-1346
US

V. Phone/Fax

Practice location:
  • Phone: 561-322-3588
  • Fax: 754-812-5993
Mailing address:
  • Phone: 561-322-3588
  • Fax: 754-812-5993

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207W00000X
TaxonomyOphthalmology Physician
License NumberME81086
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code207WX0107X
TaxonomyRetina Specialist (Ophthalmology) Physician
License NumberME81086
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: