Healthcare Provider Details

I. General information

NPI: 1568490944
Provider Name (Legal Business Name): ANIL KUMAR GUPTA M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/28/2006
Last Update Date: 09/08/2020
Certification Date: 09/08/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3312 N OAK ST EXT BLDG D
VALDOSTA GA
31605-1066
US

IV. Provider business mailing address

3312 N OAK ST EXT BLDG D
VALDOSTA GA
31605-1066
US

V. Phone/Fax

Practice location:
  • Phone: 229-244-2030
  • Fax: 229-244-2038
Mailing address:
  • Phone: 229-244-2030
  • Fax: 229-244-2038

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number045487
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: