Healthcare Provider Details

I. General information

NPI: 1659357523
Provider Name (Legal Business Name): SUNIL GUPTA MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/21/2005
Last Update Date: 03/16/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

19415 DEERFIELD AVE SUITE 303
LEESBURG VA
20176-8472
US

IV. Provider business mailing address

19415 DEERFIELD AVE STE 303
LEESBURG VA
20176-8472
US

V. Phone/Fax

Practice location:
  • Phone: 703-297-4865
  • Fax: 703-858-7740
Mailing address:
  • Phone: 703-297-4865
  • Fax: 703-858-7740

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number0101038914
License Number StateVA
# 2
Primary TaxonomyN
Taxonomy Code2080N0001X
TaxonomyNeonatal-Perinatal Medicine Physician
License Number0101038914
License Number StateVA
# 3
Primary TaxonomyN
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number0101038914
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: