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General NPI Number Information
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NPI Number | 1598033177
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Entity Type | Organization
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Legal Business Name | BERKELEY MEDICAL ASSOCIATE, PC
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Dates
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Enumeration Date | 12/09/2011
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Last Update Date | 12/09/2011
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Provider Practice Location Address
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Address Line | 207 BERKELEY PL
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City | BROOKLYN
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State | NY
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Zip | 11217-3801
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Country | US
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Telephone | 347-529-6322
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Fax | 718-638-4033
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Provider Business Mailing Address
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Address Line | PO BOX 270
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City | MASSAPEQUA PARK
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State | NY
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Zip | 11762-0270
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Country | US
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Telephone | 631-264-2035
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Fax | 631-264-1418
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Authorized Official
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Title or Position | OWNER
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Name | JAGDISH K GUPTA
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Credential | M.D.
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Telephone | 917-941-2886
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207L00000X
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Taxonomy Name | Anesthesiology Physician
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License Number | 123886
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License Number State | NY
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