1457657090 NPI number — GANESH P GUPTA MDPA

Table of content: (NPI 1457657090)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1457657090 NPI number — GANESH P GUPTA MDPA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
GANESH P GUPTA MDPA
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1457657090
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/30/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 975
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BAYTOWN
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
77522-0975
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
281-422-3576
Provider Business Mailing Address Fax Number:
281-422-0295

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1610 JAMES BOWIE DR STE A114
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BAYTOWN
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
77520-3383
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
281-422-3576
Provider Business Practice Location Address Fax Number:
281-422-0295
Provider Enumeration Date:
01/30/2011

Additional Information

Authorized Official

Authorized Official Last Name:
GUPTA
Authorized Official First Name:
GANESH
Authorized Official Middle Name:
P
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
281-422-3576

Provider Taxonomy Codes

  • Taxonomy code: 207Q00000X , with the licence number:  J4649 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 129715206 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".




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