MEDICARE: DR. MINI GUPTA M.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207Q00000X	Family Medicine Physician	25MA07795500	NJ

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1528117389
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. MINI GUPTA M.D.

Provider Business Mailing Address
First Line	:	301 LIPPINCOTT DR STE 410
Second Line	:
City	:	MARLTON
State	:	NJ
Zip	:	08053-4197
Country	:	US
Telephone Number	:	856-355-0340
Fax Number	:	856-355-0330

Provider Business Practice Location Address
First Line	:	216 HADDON AVE
Second Line	:	SUITE 100
City	:	HADDON TOWNSHIP
State	:	NJ
Zip	:	08108-2809
Country	:	US
Telephone Number	:	856-854-6600
Fax Number	:	856-854-6610

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	01/10/2007
Last Update Date	:	10/20/2020

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