Healthcare Provider Details

I. General information

NPI: 1912296773
Provider Name (Legal Business Name): DIPANKAR GUPTA MD. DCH
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/01/2011
Last Update Date: 03/08/2022
Certification Date: 03/08/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1600 SW ARCHER RD PEDIATRIC CRITICAL CARE MEDICINE RM 10-504
GAINESVILLE FL
32610-3003
US

IV. Provider business mailing address

1600 SW ARCHER RD PEDIATRIC CRITICAL CARE MEDICINE RM 10-504
GAINESVILLE FL
32610-3003
US

V. Phone/Fax

Practice location:
  • Phone: 352-265-0462
  • Fax:
Mailing address:
  • Phone: 352-265-0462
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2080P0202X
TaxonomyPediatric Cardiology Physician
License NumberME125347
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: