Provider Demographics
NPI:1144278185
Name:MOHAN L GUPTA MD PA
Entity type:Organization
Organization Name:MOHAN L GUPTA MD PA
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRES
Authorized Official - Prefix:
Authorized Official - First Name:MOHAN
Authorized Official - Middle Name:L
Authorized Official - Last Name:GUPTA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:954-742-0112
Mailing Address - Street 1:8396 WEST OAKLAND PARK BLVD
Mailing Address - Street 2:
Mailing Address - City:SUNRISE
Mailing Address - State:FL
Mailing Address - Zip Code:33351-7372
Mailing Address - Country:US
Mailing Address - Phone:954-742-0112
Mailing Address - Fax:954-746-8202
Practice Address - Street 1:8384 W OAKLAND PARK BLVD
Practice Address - Street 2:
Practice Address - City:SUNRISE
Practice Address - State:FL
Practice Address - Zip Code:33351-7372
Practice Address - Country:US
Practice Address - Phone:954-742-0112
Practice Address - Fax:954-746-8202
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-04
Last Update Date:2020-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM1300XAmbulatory Health Care FacilitiesClinic/CenterMulti-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL252966100Medicaid
FL99597Medicare PIN
FL252966100Medicaid