Healthcare Provider Details

I. General information

NPI: 1306839311
Provider Name (Legal Business Name): NISHA K GUPTA MD
Entity Type: Individual
Gender: Female
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 08/24/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

19335 ALLEN RD
BROWNSTOWN TWP MI
48183-1003
US

IV. Provider business mailing address

19335 ALLEN RD
BROWNSTOWN TWP MI
48183-1003
US

V. Phone/Fax

Practice location:
  • Phone: 734-479-5580
  • Fax: 734-479-5586
Mailing address:
  • Phone: 734-479-5580
  • Fax: 734-479-5586

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RR0500X
TaxonomyRheumatology Physician
License Number4301058689
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: