Healthcare Provider Details

I. General information

NPI: 1477562536
Provider Name (Legal Business Name): SANJIV GUPTA M.D. P.S.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/07/2006
Last Update Date: 04/28/2020
Certification Date: 04/28/2020
Deactivation Date: 07/02/2007
Reactivation Date: 11/09/2007

III. Provider practice location address

300 ST HWY 1947 SUITE A
GRAYSON KY
41143-1947
US

IV. Provider business mailing address

PO BOX 1620 300 ST HWY 1947
GRAYSON KY
41143-5620
US

V. Phone/Fax

Practice location:
  • Phone: 606-474-2200
  • Fax: 606-474-2205
Mailing address:
  • Phone: 606-474-2200
  • Fax: 606-474-2205

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number32686
License Number StateKY
# 2
Primary TaxonomyN
Taxonomy Code207RA0401X
TaxonomyAddiction Medicine (Internal Medicine) Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number32686
License Number StateKY

VIII. Authorized Official

Name: SANJIV GUPTA
Title or Position: PRESIDENT/OWNER
Credential: MD
Phone: 606-474-2200