Healthcare Provider Details

I. General information

NPI: 1255542338
Provider Name (Legal Business Name): AKSHAY GUPTA M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/24/2007
Last Update Date: 07/19/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2235 E GALA ST
MERIDIAN ID
83642-8026
US

IV. Provider business mailing address

425 W BANNOCK ST
BOISE ID
83702-6035
US

V. Phone/Fax

Practice location:
  • Phone: 208-887-3724
  • Fax: 208-887-1682
Mailing address:
  • Phone: 208-343-1702
  • Fax: 208-342-7042

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RG0100X
TaxonomyGastroenterology Physician
License NumberM-12188
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: