Healthcare Provider Details

I. General information

NPI: 1760414122
Provider Name (Legal Business Name): ANJALI GUPTA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/07/2006
Last Update Date: 10/23/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1320 S BAY ST
EUSTIS FL
32726-5551
US

IV. Provider business mailing address

1320 S BAY ST
EUSTIS FL
32726-5551
US

V. Phone/Fax

Practice location:
  • Phone: 352-530-9557
  • Fax: 352-602-7149
Mailing address:
  • Phone: 352-530-9557
  • Fax: 352-602-7149

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2084A0401X
TaxonomyAddiction Medicine (Psychiatry & Neurology) Physician
License Number036129588
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code2085R0001X
TaxonomyRadiation Oncology Physician
License Number37462
License Number StateIA
# 3
Primary TaxonomyN
Taxonomy Code2085R0001X
TaxonomyRadiation Oncology Physician
License NumberMD063886L
License Number StatePA
# 4
Primary TaxonomyY
Taxonomy Code2084A0401X
TaxonomyAddiction Medicine (Psychiatry & Neurology) Physician
License NumberME136879
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: