Healthcare Provider Details

I. General information

NPI: 1003293986
Provider Name (Legal Business Name): MS. SOMDATTA GUPTA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/30/2015
Last Update Date: 06/27/2022
Certification Date: 06/27/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

30 PROSPECT AVE
HACKENSACK NJ
07601-1915
US

IV. Provider business mailing address

30 PROSPECT AVE DEPT OF
HACKENSACK NJ
07601-1915
US

V. Phone/Fax

Practice location:
  • Phone: 973-216-7796
  • Fax:
Mailing address:
  • Phone: 973-216-7796
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License Number1003293986
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: