Healthcare Provider Details

I. General information

NPI: 1407973001
Provider Name (Legal Business Name): MALA GUPTA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/26/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5000 SAGEMORE DR STE 205
MARLTON NJ
08053-4332
US

IV. Provider business mailing address

1 CLIFFSWALLOW DR
MEDFORD NJ
08055-3805
US

V. Phone/Fax

Practice location:
  • Phone: 856-985-3030
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number25MA06259600
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: