=====================================================
General NPI Number Information
=====================================================
NPI Number | 1730212747
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ANU GUPTA MD PC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/13/2007
-----------------------------------------------------
Last Update Date | 04/08/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 10301 DEMOCRACY LN
-----------------------------------------------------
City | FAIRFAX
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 22030-2545
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 703-934-4450
-----------------------------------------------------
Fax | 703-934-5533
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 10301 DEMOCRACY LN
-----------------------------------------------------
City | FAIRFAX
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 22030-2545
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 703-934-4450
-----------------------------------------------------
Fax | 703-934-5533
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | DR. ANU GUPTA
-----------------------------------------------------
Credential | M.D.
-----------------------------------------------------
Telephone | 703-934-4450
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QM2500X
-----------------------------------------------------
Taxonomy Name | Medical Specialty Clinic/Center
-----------------------------------------------------
License Number | 0101053278
-----------------------------------------------------
License Number State | VA
-----------------------------------------------------