Healthcare Provider Details

I. General information

NPI: 1629046420
Provider Name (Legal Business Name): VICRAM GUPTA MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/09/2006
Last Update Date: 10/19/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

902 N RIVERSIDE RD STE 200
ST JOSEPH MO
64507-2559
US

IV. Provider business mailing address

902 N RIVERSIDE RD STE 200
ST JOSEPH MO
64507-2559
US

V. Phone/Fax

Practice location:
  • Phone: 816-271-1301
  • Fax: 816-271-1302
Mailing address:
  • Phone: 816-271-1301
  • Fax: 816-271-1302

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207RX0202X
TaxonomyMedical Oncology Physician
License Number0427852
License Number StateKS
# 2
Primary TaxonomyY
Taxonomy Code207RX0202X
TaxonomyMedical Oncology Physician
License Number107588
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: