Healthcare Provider Details

I. General information

NPI: 1154325694
Provider Name (Legal Business Name): ANIL GUPTA MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/13/2005
Last Update Date: 04/11/2025
Certification Date: 04/11/2025
Deactivation Date: 03/16/2006
Reactivation Date: 03/21/2006

III. Provider practice location address

1624 CROSBY AVE
BRONX NY
10461-5255
US

IV. Provider business mailing address

1624 CROSBY AVE
BRONX NY
10461-5201
US

V. Phone/Fax

Practice location:
  • Phone: 718-822-0676
  • Fax: 718-822-6516
Mailing address:
  • Phone: 718-822-0676
  • Fax: 718-822-6516

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number174785
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code2080P0201X
TaxonomyPediatric Allergy/Immunology Physician
License Number174785
License Number StateNY
# 3
Primary TaxonomyY
Taxonomy Code207K00000X
TaxonomyAllergy & Immunology Physician
License Number174785
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: