Healthcare Provider Details

I. General information

NPI: 1013113364
Provider Name (Legal Business Name): NITIN GUPTA M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/25/2007
Last Update Date: 10/03/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

980 JOHNSON FY RD NE STE 820
ATLANTA GA
30342-1608
US

IV. Provider business mailing address

1001 SUMMIT BLVD STE B
BROOKHAVEN GA
30319-6408
US

V. Phone/Fax

Practice location:
  • Phone: 404-252-9307
  • Fax: 404-252-5839
Mailing address:
  • Phone: 770-989-1668
  • Fax: 678-388-1759

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number22586
License Number StateMS
# 2
Primary TaxonomyN
Taxonomy Code207RG0100X
TaxonomyGastroenterology Physician
License Number249386
License Number StateMA
# 3
Primary TaxonomyN
Taxonomy Code207RG0100X
TaxonomyGastroenterology Physician
License Number22586
License Number StateMS
# 4
Primary TaxonomyY
Taxonomy Code207RG0100X
TaxonomyGastroenterology Physician
License Number078939
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: