Provider Demographics
NPI:1861476152
Name:GUPTON, HENRY LEWIS (MD)
Entity type:Individual
Prefix:
First Name:HENRY
Middle Name:LEWIS
Last Name:GUPTON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:110 EXECUTIVE PARK DR
Mailing Address - Street 2:
Mailing Address - City:CLINTON
Mailing Address - State:TN
Mailing Address - Zip Code:37716-6876
Mailing Address - Country:US
Mailing Address - Phone:865-494-9241
Mailing Address - Fax:865-494-0895
Practice Address - Street 1:110 EXECUTIVE PARK DR
Practice Address - Street 2:
Practice Address - City:CLINTON
Practice Address - State:TN
Practice Address - Zip Code:37716-6876
Practice Address - Country:US
Practice Address - Phone:865-494-9241
Practice Address - Fax:865-494-0895
Is Sole Proprietor?:No
Enumeration Date:2005-12-01
Last Update Date:2013-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNMD0000019752207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3045736Medicaid
TN3720017Medicare PIN
B92548Medicare UPIN