Healthcare Provider Details

I. General information

NPI: 1083398101
Provider Name (Legal Business Name): AMIT GUPTA M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/09/2023
Last Update Date: 07/07/2026
Certification Date: 07/07/2026
Deactivation Date: 01/12/2024
Reactivation Date: 02/06/2024

III. Provider practice location address

20 HOSPITAL DR
LOGAN WV
25601-3452
US

IV. Provider business mailing address

20 HOSPITAL DR
LOGAN WV
25601-3452
US

V. Phone/Fax

Practice location:
  • Phone: 304-831-1101
  • Fax:
Mailing address:
  • Phone: 304-831-1101
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number36432
License Number StateWV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: