=====================================================
General NPI Number Information
=====================================================
NPI Number | 1457560443
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | SANJEEV K GUPTA M.D.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/22/2007
-----------------------------------------------------
Last Update Date | 08/12/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4515 WILES RD STE 201
-----------------------------------------------------
City | COCONUT CREEK
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33073-3414
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 954-943-1133
-----------------------------------------------------
Fax | 954-783-6845
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 5258 LINTON BLVD STE 203
-----------------------------------------------------
City | DELRAY BEACH
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33484-6529
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 561-495-7570
-----------------------------------------------------
Fax | 561-496-7074
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 208800000X
-----------------------------------------------------
Taxonomy Name | Urology Physician
-----------------------------------------------------
License Number | ME105426
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 208800000X
-----------------------------------------------------
Taxonomy Name | Urology Physician
-----------------------------------------------------
License Number | 37691
-----------------------------------------------------
License Number State | IA
-----------------------------------------------------