Healthcare Provider Details

I. General information

NPI: 1255492260
Provider Name (Legal Business Name): REENA GUPTA OD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/13/2006
Last Update Date: 10/03/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1544 PIEDMONT AVE NE SUITE 320
ATLANTA GA
30324-5018
US

IV. Provider business mailing address

1635 WILDWOOD RD NE
ATLANTA GA
30306-3018
US

V. Phone/Fax

Practice location:
  • Phone: 404-888-9444
  • Fax: 404-888-9666
Mailing address:
  • Phone: 404-580-8457
  • Fax: 404-888-9666

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License NumberOPT002285
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: