Healthcare Provider Details

I. General information

NPI: 1487643342
Provider Name (Legal Business Name): SURYA N GUPTA MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/13/2005
Last Update Date: 07/18/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4803 KENTUCKY STREET CAMC PEDIATRIC NEUROLOGY
SOUTH CHARLESTON WV
25309-1547
US

IV. Provider business mailing address

PO BOX 1547 CAMC PEDIATRIC NEUROLOGY
CHARLESTON WV
25326-1547
US

V. Phone/Fax

Practice location:
  • Phone: 304-766-7695
  • Fax: 603-663-3229
Mailing address:
  • Phone: 304-388-7183
  • Fax: 304-388-7176

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2080P0008X
TaxonomyPediatric Neurodevelopmental Disabilities Physician
License NumberMD057895L
License Number StatePA
# 2
Primary TaxonomyY
Taxonomy Code2084N0402X
TaxonomyNeurology with Special Qualifications in Child Neurology Physician
License Number15026
License Number StateNH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: