Healthcare Provider Details

I. General information

NPI: 1750538609
Provider Name (Legal Business Name): VIKRAM GUPTA M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/22/2008
Last Update Date: 10/02/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

246 CLIFTON AVE STE 4
CLIFTON NJ
07011-1953
US

IV. Provider business mailing address

PO BOX 3399
WAYNE NJ
07474-3399
US

V. Phone/Fax

Practice location:
  • Phone: 973-330-6765
  • Fax: 973-939-8489
Mailing address:
  • Phone: 973-330-6765
  • Fax: 973-939-8489

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number25MA08471700
License Number StateNJ
# 2
Primary TaxonomyN
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number25MA08471700
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: