Healthcare Provider Details

I. General information

NPI: 1619123445
Provider Name (Legal Business Name): RONALD S. GUP, MD, PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/12/2008
Last Update Date: 10/27/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4060 SHERIDAN ST SUITE B
HOLLYWOOD FL
33021-3559
US

IV. Provider business mailing address

4060 SHERIDAN ST SUITE B
HOLLYWOOD FL
33021-3559
US

V. Phone/Fax

Practice location:
  • Phone: 954-966-9001
  • Fax: 954-985-0456
Mailing address:
  • Phone: 954-966-9001
  • Fax: 954-985-0456

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RP1001X
TaxonomyPulmonary Disease Physician
License Number44479
License Number StateFL

VIII. Authorized Official

Name: DR. RONALD S GUP
Title or Position: PRESIDENT CEO
Credential: MD
Phone: 954-966-9001