=====================================================
General NPI Number Information
=====================================================
NPI Number | 1962636217
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | A GUPTA MD PA
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/14/2009
-----------------------------------------------------
Last Update Date | 05/14/2009
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3300 W LAKE MARY BLVD
-----------------------------------------------------
City | LAKE MARY
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32746-3570
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 407-321-7111
-----------------------------------------------------
Fax | 407-321-7446
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3300 W LAKE MARY BLVD
-----------------------------------------------------
City | LAKE MARY
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32746-3570
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 407-321-7111
-----------------------------------------------------
Fax | 407-321-7446
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | DR. ANITA GUPTA
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 407-321-7111
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number | ME0073977
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------