Healthcare Provider Details

I. General information

NPI: 1255528618
Provider Name (Legal Business Name): MAMTA BANSAL GUPTA MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/01/2007
Last Update Date: 03/05/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

27 WILLS WAY
PISCATAWAY NJ
08854-3770
US

IV. Provider business mailing address

27 WILLS WAY
PISCATAWAY NJ
08854-3770
US

V. Phone/Fax

Practice location:
  • Phone: 908-834-8534
  • Fax: 908-922-4880
Mailing address:
  • Phone: 908-834-8534
  • Fax: 908-922-4880

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number25MA08120400
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: