MEDICARE: PREM K GUPTA MD PC

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	207RC0000X	Cardiovascular Disease Physician	108782	NY

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	:	1831170224
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PREM K GUPTA MD PC

Provider Business Mailing Address
First Line	:	4709 FORT HAMILTON PKWY
Second Line	:
City	:	BROOKLYN
State	:	NY
Zip	:	11219-2927
Country	:	US
Telephone Number	:	718-633-4244
Fax Number	:	718-437-1556

Provider Business Practice Location Address
First Line	:	4709 FORT HAMILTON PKWY
Second Line	:
City	:	BROOKLYN
State	:	NY
Zip	:	11219-2927
Country	:	US
Telephone Number	:	718-633-4244
Fax Number	:	718-437-1556

Authorized Official
Title or Position	:	PRESIDENT OWNER
Name	:	PREM K GUPTA
Credential	:	MD
Telephone Number	:	718-633-4244

Provider Enumeration Date	:	11/11/2005
Last Update Date	:	09/24/2007

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