Healthcare Provider Details

I. General information

NPI: 1790735181
Provider Name (Legal Business Name): BHAVDEEP K GUPTA MD, FACC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/10/2006
Last Update Date: 02/25/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1030 HILLPOINT BLVD N
SUFFOLK VA
23434-8470
US

IV. Provider business mailing address

7007 HARBOUR VIEW BLVD SUITE 108
SUFFOLK VA
23435-3657
US

V. Phone/Fax

Practice location:
  • Phone: 757-539-0444
  • Fax: 757-539-4824
Mailing address:
  • Phone: 757-215-2784
  • Fax: 757-215-2728

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code174400000X
TaxonomySpecialist
License Number0101051058
License Number StateVA
# 2
Primary TaxonomyY
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License Number0101051058
License Number StateVA
# 3
Primary TaxonomyN
Taxonomy Code207UN0901X
TaxonomyNuclear Cardiology Physician
License Number0101051058
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: