Healthcare Provider Details

I. General information

NPI: 1497878581
Provider Name (Legal Business Name): GUPTA GASTRO ASSOCIATE OFFICE BASED SURGERY, P.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/06/2007
Last Update Date: 11/19/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

130 AVENUE P
BROOKLYN NY
11204-6362
US

IV. Provider business mailing address

130 AVENUE P
BROOKLYN NY
11204-6362
US

V. Phone/Fax

Practice location:
  • Phone: 718-372-7434
  • Fax: 718-266-2663
Mailing address:
  • Phone: 718-372-7434
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QE0800X
TaxonomyEndoscopy Clinic/Center
License Number148223
License Number StateNY

VIII. Authorized Official

Name: MR. NEVILLE GUPTA
Title or Position: ADMINISTRATOR
Credential:
Phone: 718-372-7434