Healthcare Provider Details

I. General information

NPI: 1134308109
Provider Name (Legal Business Name): PREM K GUPTA MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/26/2007
Last Update Date: 10/26/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4709 FT HAMILTON PARKWAY
BROOKLYN NY
11219-2927
US

IV. Provider business mailing address

4709 FT HAMILTON PARKWAY
BROOKLYN NY
11219-2927
US

V. Phone/Fax

Practice location:
  • Phone: 718-633-4244
  • Fax: 718-437-1556
Mailing address:
  • Phone: 718-633-4244
  • Fax: 718-437-1556

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License Number108782
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: