Healthcare Provider Details

I. General information

NPI: 1376645002
Provider Name (Legal Business Name): SURESH C GUPTA MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/02/2006
Last Update Date: 05/02/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1510 S STATE RD SUITE A
DAVISON MI
48423-1965
US

IV. Provider business mailing address

7330 SAN PEDRO AVE STE 540
SAN ANTONIO TX
78216-6250
US

V. Phone/Fax

Practice location:
  • Phone: 810-653-0899
  • Fax: 810-653-4144
Mailing address:
  • Phone: 210-344-7287
  • Fax: 210-344-2649

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberP4761
License Number StateTX
# 2
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number4301037942
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: