=====================================================
General NPI Number Information
=====================================================
NPI Number | 1255492260
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | REENA GUPTA OD
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/13/2006
-----------------------------------------------------
Last Update Date | 10/03/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1544 PIEDMONT AVE NE SUITE 320
-----------------------------------------------------
City | ATLANTA
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30324-5018
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 404-888-9444
-----------------------------------------------------
Fax | 404-888-9666
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1635 WILDWOOD RD NE
-----------------------------------------------------
City | ATLANTA
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30306-3018
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 404-580-8457
-----------------------------------------------------
Fax | 404-888-9666
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 152W00000X
-----------------------------------------------------
Taxonomy Name | Optometrist
-----------------------------------------------------
License Number | OPT002285
-----------------------------------------------------
License Number State | GA
-----------------------------------------------------