Healthcare Provider Details

I. General information

NPI: 1295791994
Provider Name (Legal Business Name): MOHAN L GUPTA MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/22/2006
Last Update Date: 12/07/2020
Certification Date: 12/07/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8396 W OAKLAND PARK BLVD
SUNRISE FL
33351-7372
US

IV. Provider business mailing address

8396 W OAKLAND PARK BLVD
SUNRISE FL
33351-7372
US

V. Phone/Fax

Practice location:
  • Phone: 954-742-0112
  • Fax: 954-746-8202
Mailing address:
  • Phone: 954-742-0112
  • Fax: 954-746-8202

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberME0039177
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: