Healthcare Provider Details

I. General information

NPI: 1912326331
Provider Name (Legal Business Name): MS. SIDDHI GUPTA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/14/2014
Last Update Date: 08/18/2021
Certification Date: 08/18/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1900 RANDOLPH RD STE 216
CHARLOTTE NC
28207-1106
US

IV. Provider business mailing address

PO BOX 60447
CHARLOTTE NC
28260-0447
US

V. Phone/Fax

Practice location:
  • Phone: 704-316-5330
  • Fax: 704-316-5332
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RI0200X
TaxonomyInfectious Disease Physician
License Number2020-03845
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: