Healthcare Provider Details

I. General information

NPI: 1568620003
Provider Name (Legal Business Name): NITIN KUMAR GUPTA MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/31/2008
Last Update Date: 09/21/2022
Certification Date: 09/21/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

27177 LAHSER RD STE 103
SOUTHFIELD MI
48034-8467
US

IV. Provider business mailing address

6725 COLBY LN
BLOOMFIELD MI
48301-2948
US

V. Phone/Fax

Practice location:
  • Phone: 248-357-1360
  • Fax:
Mailing address:
  • Phone: 248-357-1360
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RI0011X
TaxonomyInterventional Cardiology Physician
License Number4301110024
License Number StateMI
# 2
Primary TaxonomyN
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License Number036.161833
License Number StateIL
# 3
Primary TaxonomyN
Taxonomy Code207RI0011X
TaxonomyInterventional Cardiology Physician
License Number036.161833
License Number StateIL
# 4
Primary TaxonomyN
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License Number4301110024
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: