Healthcare Provider Details

I. General information

NPI: 1184886152
Provider Name (Legal Business Name): DAVE S GUPTA M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/30/2008
Last Update Date: 03/21/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4265 FIVE OAKS DR
LANSING MI
48911-4214
US

IV. Provider business mailing address

4265 FIVE OAKS DR
LANSING MI
48911-4214
US

V. Phone/Fax

Practice location:
  • Phone: 517-484-2261
  • Fax: 517-484-6666
Mailing address:
  • Phone: 517-484-2261
  • Fax: 517-484-6666

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207RA0201X
TaxonomyAllergy & Immunology (Internal Medicine) Physician
License Number4301102279
License Number StateMI
# 2
Primary TaxonomyY
Taxonomy Code207K00000X
TaxonomyAllergy & Immunology Physician
License Number4301102279
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: