Healthcare Provider Details

I. General information

NPI: 1073870002
Provider Name (Legal Business Name): CHARU GUPTA M.B.B.S
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/16/2012
Last Update Date: 01/30/2026
Certification Date: 01/30/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

MEDICAL CENTER BLVD
WINSTON SALEM NC
27157-0001
US

IV. Provider business mailing address

MEDICAL CENTER BLVD
WINSTON SALEM NC
27157-0001
US

V. Phone/Fax

Practice location:
  • Phone: 336-713-4500
  • Fax: 336-713-4501
Mailing address:
  • Phone: 336-713-4500
  • Fax: 336-713-4501

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number01070848A
License Number StateIN
# 2
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number2025-03683
License Number StateNC
# 3
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberMD040608
License Number StateDC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: