Healthcare Provider Details

I. General information

NPI: 1528485729
Provider Name (Legal Business Name): SANDEEPKUMAR JAGDISHBHAI GUPTA M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/25/2014
Last Update Date: 05/24/2023
Certification Date: 05/24/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

120 WILLIAM PENN PLZ
DURHAM NC
27704-2150
US

IV. Provider business mailing address

120 WILLIAM PENN PLZ
DURHAM NC
27704-2150
US

V. Phone/Fax

Practice location:
  • Phone: 919-220-5255
  • Fax: 919-220-6971
Mailing address:
  • Phone: 919-220-5255
  • Fax: 919-220-6971

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number81788
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number56620
License Number StateTN
# 3
Primary TaxonomyN
Taxonomy Code208M00000X
TaxonomyHospitalist Physician
License Number2020-04827
License Number StateNC
# 4
Primary TaxonomyY
Taxonomy Code207RR0500X
TaxonomyRheumatology Physician
License Number2020-04827
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: