Healthcare Provider Details

I. General information

NPI: 1679773642
Provider Name (Legal Business Name): SHUCHITA GUPTA MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/18/2007
Last Update Date: 03/21/2022
Certification Date: 03/21/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1350 WALTON WAY
AUGUSTA GA
30901
US

IV. Provider business mailing address

PO BOX 1705
AUGUSTA GA
30903-1705
US

V. Phone/Fax

Practice location:
  • Phone: 706-774-7855
  • Fax: 706-774-8620
Mailing address:
  • Phone: 706-774-7855
  • Fax: 706-774-8620

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License Number081829
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License NumberMD450523
License Number StatePA
# 3
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License NumberMT189781
License Number StatePA
# 4
Primary TaxonomyY
Taxonomy Code207RA0001X
TaxonomyAdvanced Heart Failure and Transplant Cardiology Physician
License Number081829
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: