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General NPI Number Information
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NPI Number | 1598769176
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Entity Type | Individual
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Provider Name | KRISHAN KUMAR GUPTA M.D.
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Gender | Male
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Dates
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Enumeration Date | 06/10/2005
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Last Update Date | 03/25/2021
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Provider Practice Location Address
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Address Line | 1059 RIDGEWOOD PL
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City | JACKSON
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State | MS
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Zip | 39211-2018
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Country | US
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Telephone | 601-957-3211
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Fax | 601-957-9753
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Provider Business Mailing Address
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Address Line | PO BOX 13531
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City | JACKSON
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State | MS
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Zip | 39236-3531
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Country | US
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Telephone | 601-957-3211
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Fax | 601-957-9753
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207Q00000X
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Taxonomy Name | Family Medicine Physician
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License Number | 12941
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License Number State | MS
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Taxonomy #2
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Taxonomy Code | 2084P0800X
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Taxonomy Name | Psychiatry Physician
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License Number | 12941
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License Number State | MS
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