Healthcare Provider Details

I. General information

NPI: 1376963132
Provider Name (Legal Business Name): GEETIKA CHOUDHARY GUPTA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/21/2014
Last Update Date: 01/21/2024
Certification Date: 01/21/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2525 CUMBERLAND PKWY SE
ATLANTA GA
30339-3915
US

IV. Provider business mailing address

710 BASS WAY
ATLANTA GA
30328-4828
US

V. Phone/Fax

Practice location:
  • Phone: 678-392-8452
  • Fax:
Mailing address:
  • Phone: 678-392-8452
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number80117
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: