Healthcare Provider Details

I. General information

NPI: 1760641153
Provider Name (Legal Business Name): DEEPTI GUPTA MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/02/2008
Last Update Date: 03/27/2021
Certification Date: 03/27/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4420 LAKE BOONE TRL
RALEIGH NC
27607
US

IV. Provider business mailing address

4420 LAKE BOONE TRL
RALEIGH NC
27607-7505
US

V. Phone/Fax

Practice location:
  • Phone: 919-784-7093
  • Fax:
Mailing address:
  • Phone: 919-784-7093
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208M00000X
TaxonomyHospitalist Physician
License Number2011-01468
License Number StateNC
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number2011-01468
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: