Healthcare Provider Details

I. General information

NPI: 1558360693
Provider Name (Legal Business Name): SANJEEV GUPTA MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/20/2005
Last Update Date: 09/03/2024
Certification Date: 09/03/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

31 HOSPITAL DR
MASSENA NY
13662
US

IV. Provider business mailing address

31 HOSPITAL DR
MASSENA NY
13662
US

V. Phone/Fax

Practice location:
  • Phone: 315-769-1099
  • Fax: 315-769-1077
Mailing address:
  • Phone: 315-769-1099
  • Fax: 315-769-1077

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number210511
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code2080A0000X
TaxonomyPediatric Adolescent Medicine Physician
License Number210511
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: