Healthcare Provider Details

I. General information

NPI: 1508639857
Provider Name (Legal Business Name): MAYANK GUPTA MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/30/2023
Last Update Date: 07/22/2024
Certification Date: 07/22/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

MAIMONIDES MEDICAL CENTER 4802 10TH AVE
BROOKLYN NY
11219
US

IV. Provider business mailing address

MAIMONIDES MEDICAL CENTER 4802 10TH AVE
BROOKLYN NY
11219
US

V. Phone/Fax

Practice location:
  • Phone: 719-283-6000
  • Fax:
Mailing address:
  • Phone: 719-283-6000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License Number60-P124105-01
License Number StateNY
# 2
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: