Healthcare Provider Details

I. General information

NPI: 1356260749
Provider Name (Legal Business Name): SANJANA GUPTA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/10/2026
Last Update Date: 07/10/2026
Certification Date: 07/11/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5620 W UNIVERSITY DR
PROSPER TX
75078-3830
US

IV. Provider business mailing address

4504 DALROCK DR
PLANO TX
75024-7725
US

V. Phone/Fax

Practice location:
  • Phone: 972-346-6135
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number11703TG
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: