Healthcare Provider Details

I. General information

NPI: 1780817460
Provider Name (Legal Business Name): MANOJ K GUPTA M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/28/2009
Last Update Date: 02/04/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3415 BAINBRIDGE AVE
BRONX NY
10467-2403
US

IV. Provider business mailing address

3415 BAINBRIDGE AVE
BRONX NY
10467-2403
US

V. Phone/Fax

Practice location:
  • Phone: 718-741-2487
  • Fax:
Mailing address:
  • Phone: 718-741-2487
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2080P0202X
TaxonomyPediatric Cardiology Physician
License Number0101258037
License Number StateVA
# 2
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number4301094670
License Number StateMI
# 3
Primary TaxonomyN
Taxonomy Code2080P0202X
TaxonomyPediatric Cardiology Physician
License Number098759
License Number StateOH
# 4
Primary TaxonomyN
Taxonomy Code2080P0202X
TaxonomyPediatric Cardiology Physician
License Number52737
License Number StateTN
# 5
Primary TaxonomyY
Taxonomy Code2080P0202X
TaxonomyPediatric Cardiology Physician
License Number296718
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: