Healthcare Provider Details

I. General information

NPI: 1013992528
Provider Name (Legal Business Name): ROM M GUPTA M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/07/2005
Last Update Date: 08/15/2025
Certification Date: 08/15/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

17660 UNION TPKE STE 350
FRESH MEADOWS NY
11366-1531
US

IV. Provider business mailing address

17561 HILLSIDE AVE STE 402
JAMAICA NY
11432-5769
US

V. Phone/Fax

Practice location:
  • Phone: 718-521-6200
  • Fax:
Mailing address:
  • Phone: 718-291-0488
  • Fax: 718-291-0888

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RG0100X
TaxonomyGastroenterology Physician
License Number189770
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number189770
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: