Healthcare Provider Details

I. General information

NPI: 1942390729
Provider Name (Legal Business Name): ASHISH K GUPTA MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/13/2006
Last Update Date: 09/16/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1399 JENKS AVE # 12
PANAMA CITY FL
32401-2442
US

IV. Provider business mailing address

1399 JENKS AVE # 12
PANAMA CITY FL
32401-2442
US

V. Phone/Fax

Practice location:
  • Phone: 850-532-6303
  • Fax: 850-307-5402
Mailing address:
  • Phone: 850-532-6303
  • Fax: 850-307-5402

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2086S0129X
TaxonomyVascular Surgery Physician
License NumberME113628
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: