Healthcare Provider Details

I. General information

NPI: 1689844268
Provider Name (Legal Business Name): VIKESH GUPTA M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/10/2008
Last Update Date: 10/19/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 HOSPITAL DR # DC043.00
COLUMBIA MO
65201-5276
US

IV. Provider business mailing address

1 HOSPITAL DRIVE, DC043.00
COLUMBIA MO
65212
UG

V. Phone/Fax

Practice location:
  • Phone: 573-882-4464
  • Fax: 573-884-8142
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number125.052431
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number2010041792
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: