Healthcare Provider Details

I. General information

NPI: 1043775976
Provider Name (Legal Business Name): SAMPLE MEDICAL CENTER, P.A.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/05/2019
Last Update Date: 07/02/2026
Certification Date: 07/02/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5596 W SAMPLE RD
MARGATE FL
33073-3423
US

IV. Provider business mailing address

5596 W SAMPLE RD
MARGATE FL
33073-3423
US

V. Phone/Fax

Practice location:
  • Phone: 954-968-4000
  • Fax:
Mailing address:
  • Phone: 954-968-4000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code261QP2300X
TaxonomyPrimary Care Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: NEENA R GUPTA
Title or Position: AUTHORIZED OFFICIAL
Credential: DO
Phone: 954-968-4000