Healthcare Provider Details

I. General information

NPI: 1043293996
Provider Name (Legal Business Name): SAMEER GUPTA MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/23/2005
Last Update Date: 02/28/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4906 FREDERICK AVE
SAINT JOSEPH MO
64506-3246
US

IV. Provider business mailing address

4906 FREDERICK AVE
SAINT JOSEPH MO
64506-3246
US

V. Phone/Fax

Practice location:
  • Phone: 816-396-0245
  • Fax: 816-817-5746
Mailing address:
  • Phone: 816-396-0245
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number2005006001
License Number StateMO
# 2
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number01060297A
License Number StateIN
# 3
Primary TaxonomyY
Taxonomy Code202K00000X
TaxonomyPhlebology Physician
License Number2005006001
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: