Healthcare Provider Details

I. General information

NPI: 1528273406
Provider Name (Legal Business Name): ASHEESH GUPTA M.D., M.P.H.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/13/2007
Last Update Date: 10/04/2022
Certification Date: 10/04/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

14605 POTOMAC BRANCH DR SUITE 300
WOODBRIDGE VA
22191-3336
US

IV. Provider business mailing address

14605 POTOMAC BRANCH DR SUITE 300
WOODBRIDGE VA
22191-3336
US

V. Phone/Fax

Practice location:
  • Phone: 703-490-1112
  • Fax:
Mailing address:
  • Phone: 703-490-1112
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207XX0005X
TaxonomySports Medicine (Orthopaedic Surgery) Physician
License Number0101256548
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: