MEDICARE: DR. JYOTI 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	207R00000X	Internal Medicine Physician	078630	GA
2	390200000X	Student in an Organized Health Care Education/Training Program
3	208M00000X	Hospitalist Physician	078630	GA

General Provider Information

NPI Number	:	1770993222
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. JYOTI GUPTA M.D.

Provider Business Mailing Address
First Line	:	297 E PACES FERRY RD NE UNIT N912
Second Line	:
City	:	ATLANTA
State	:	GA
Zip	:	30305-2315
Country	:	US
Telephone Number	:	718-539-4227
Fax Number	:

Provider Business Practice Location Address
First Line	:	1364 CLIFTON RD NE
Second Line	:
City	:	ATLANTA
State	:	GA
Zip	:	30322-2337
Country	:	US
Telephone Number	:	347-497-1514
Fax Number	:

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

Provider Enumeration Date	:	05/06/2014
Last Update Date	:	10/05/2017

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