Healthcare Provider Details

I. General information

NPI: 1699961185
Provider Name (Legal Business Name): ASHA GUPTA, MD
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/19/2007
Last Update Date: 03/19/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

260 RIVERSIDE DR
JOHNSON CITY NY
13790-2745
US

IV. Provider business mailing address

260 RIVERSIDE DR
JOHNSON CITY NY
13790-2745
US

V. Phone/Fax

Practice location:
  • Phone: 607-798-7811
  • Fax: 607-770-7035
Mailing address:
  • Phone: 607-798-7811
  • Fax: 607-770-7035

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207K00000X
TaxonomyAllergy & Immunology Physician
License Number124306
License Number StateNY

VIII. Authorized Official

Name: GWEN SPAULDING
Title or Position: OFFFICE MANAGER
Credential: MEDICAL ASSISTANT
Phone: 607-798-7811