Healthcare Provider Details

I. General information

NPI: 1073744421
Provider Name (Legal Business Name): SHIPRA GUPTA M.D
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/03/2009
Last Update Date: 11/15/2024
Certification Date: 11/15/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

111 E 210TH ST
BRONX NY
10467-2401
US

IV. Provider business mailing address

3411 WAYNE AVE FL 7
BRONX NY
10467-2552
US

V. Phone/Fax

Practice location:
  • Phone: 718-920-4321
  • Fax:
Mailing address:
  • Phone: 718-741-2470
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number325810
License Number StateNY
# 2
Primary TaxonomyY
Taxonomy Code2080P0208X
TaxonomyPediatric Infectious Diseases Physician
License Number325810
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: