Healthcare Provider Details

I. General information

NPI: 1174039044
Provider Name (Legal Business Name): ANTOINETTE GUPTA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/14/2017
Last Update Date: 12/14/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1701 TWIN SPRINGS RD
HALETHORPE MD
21227-3553
US

IV. Provider business mailing address

35 CASTLE CLIFF CT
SILVER SPRING MD
20904-5420
US

V. Phone/Fax

Practice location:
  • Phone: 301-384-2303
  • Fax:
Mailing address:
  • Phone: 301-742-1607
  • Fax: 301-384-2303

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code246ZC0007X
TaxonomySurgical Assistant
License Number15-627
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: