Healthcare Provider Details

I. General information

NPI: 1710472725
Provider Name (Legal Business Name): SHABNUM GUPTA MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/22/2018
Last Update Date: 06/13/2022
Certification Date: 06/13/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2400 32ND AVE S
FARGO ND
58103-5800
US

IV. Provider business mailing address

PO BOX 5074
SIOUX FALLS SD
57117-5074
US

V. Phone/Fax

Practice location:
  • Phone: 701-234-2000
  • Fax: 701-234-8803
Mailing address:
  • Phone: 605-328-6585
  • Fax: 605-312-9802

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberRL15079
License Number StateND

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: