Healthcare Provider Details

I. General information

NPI: 1467443218
Provider Name (Legal Business Name): ASHWINI K. GUPTA MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/01/2005
Last Update Date: 12/11/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

405 ARROWHEAD BLVD
JONESBORO GA
30236-1254
US

IV. Provider business mailing address

236 MONTROSE DR
MCDONOUGH GA
30253-4242
US

V. Phone/Fax

Practice location:
  • Phone: 770-478-9877
  • Fax: 770-478-2908
Mailing address:
  • Phone: 770-389-9852
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License Number025981
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code208VP0000X
TaxonomyPain Medicine Physician
License Number025981
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: