Healthcare Provider Details

I. General information

NPI: 1639495526
Provider Name (Legal Business Name): KHYATI GUPTA D.O.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/16/2010
Last Update Date: 05/16/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

170 S GREEN VALLEY PKWY STE 300
HENDERSON NV
89012
US

IV. Provider business mailing address

170 S GREEN VALLEY PKWY STE 300
HENDERSON NV
89012-3145
US

V. Phone/Fax

Practice location:
  • Phone: 702-357-8811
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number255840
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: