Healthcare Provider Details

I. General information

NPI: 1275516338
Provider Name (Legal Business Name): VISHAL GUPTA M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/22/2005
Last Update Date: 07/29/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1184 5TH AVE BOX 1236
NEW YORK NY
10029-6503
US

IV. Provider business mailing address

1184 5TH AVE BOX 1236
NEW YORK NY
10029-6503
US

V. Phone/Fax

Practice location:
  • Phone: 212-241-7818
  • Fax: 212-410-7194
Mailing address:
  • Phone: 212-241-7818
  • Fax: 212-410-7194

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2085R0001X
TaxonomyRadiation Oncology Physician
License NumberA90307
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code2085R0001X
TaxonomyRadiation Oncology Physician
License Number252361
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: