Healthcare Provider Details

I. General information

NPI: 1598769176
Provider Name (Legal Business Name): KRISHAN KUMAR GUPTA M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/10/2005
Last Update Date: 03/25/2021
Certification Date: 03/25/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1059 RIDGEWOOD PL
JACKSON MS
39211-2018
US

IV. Provider business mailing address

PO BOX 13531
JACKSON MS
39236-3531
US

V. Phone/Fax

Practice location:
  • Phone: 601-957-3211
  • Fax: 601-957-9753
Mailing address:
  • Phone: 601-957-3211
  • Fax: 601-957-9753

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number12941
License Number StateMS
# 2
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number12941
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: