Healthcare Provider Details

I. General information

NPI: 1770793010
Provider Name (Legal Business Name): AMITA GUPTA PT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/23/2007
Last Update Date: 12/01/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5755 NORTHPOINT PKWY SUITE 56
ALPHARETTA GA
30022-1145
US

IV. Provider business mailing address

5755 NORTHPOINT PKWY SUITE 56
ALPHARETTA GA
30022-1145
US

V. Phone/Fax

Practice location:
  • Phone: 678-431-1301
  • Fax:
Mailing address:
  • Phone: 678-431-1301
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License NumberPT005421
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: