Healthcare Provider Details

I. General information

NPI: 1255534087
Provider Name (Legal Business Name): LONG BEACH RHEUMATOLOGY, PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/08/2007
Last Update Date: 10/10/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

759 LINCOLN BLVD
LONG BEACH NY
11561-2355
US

IV. Provider business mailing address

14 E OLIVE ST
LONG BEACH NY
11561-3507
US

V. Phone/Fax

Practice location:
  • Phone: 516-897-3885
  • Fax: 516-897-3887
Mailing address:
  • Phone: 516-897-3885
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RR0500X
TaxonomyRheumatology Physician
License Number212451
License Number StateNY

VIII. Authorized Official

Name: DR. SANDEEP GUPTA
Title or Position: PRESIDENT
Credential: MD
Phone: 516-897-3885