Healthcare Provider Details

I. General information

NPI: 1750343489
Provider Name (Legal Business Name): MALA GUPTA M.D., F.I.A.C.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/06/2006
Last Update Date: 06/10/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

222 STATION PLZ N SUITE 606
MINEOLA NY
11501-3808
US

IV. Provider business mailing address

222 STATION PLZ N STE 606
MINEOLA NY
11501-3893
US

V. Phone/Fax

Practice location:
  • Phone: 516-663-4533
  • Fax: 516-663-8824
Mailing address:
  • Phone: 516-663-4533
  • Fax: 516-663-8824

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207ZC0500X
TaxonomyCytopathology Physician
License Number187402
License Number StateNY
# 2
Primary TaxonomyY
Taxonomy Code207ZP0102X
TaxonomyAnatomic Pathology & Clinical Pathology Physician
License Number187402
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: