Provider Demographics
NPI:1902039597
Name:GUPTA, AMIT
Entity Type:Individual
Prefix:
First Name:AMIT
Middle Name:
Last Name:GUPTA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:27200 PARKVIEW BLVD
Mailing Address - Street 2:APT 712
Mailing Address - City:WARREN
Mailing Address - State:MI
Mailing Address - Zip Code:48092-2884
Mailing Address - Country:US
Mailing Address - Phone:940-594-7827
Mailing Address - Fax:
Practice Address - Street 1:35746 HARPER AVE
Practice Address - Street 2:
Practice Address - City:CLINTON TOWNSHIP
Practice Address - State:MI
Practice Address - Zip Code:48035-3212
Practice Address - Country:US
Practice Address - Phone:586-791-9203
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-08-28
Last Update Date:2009-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5501014709225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist