Provider Demographics
NPI:1487761243
Name:GUPTA, SANJIV (MD)
Entity type:Individual
Prefix:DR
First Name:SANJIV
Middle Name:
Last Name:GUPTA
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:PO BOX 1620
Mailing Address - Street 2:300 STATE HWY 1947
Mailing Address - City:GRAYSON
Mailing Address - State:KY
Mailing Address - Zip Code:41143
Mailing Address - Country:US
Mailing Address - Phone:606-474-2200
Mailing Address - Fax:606-474-2205
Practice Address - Street 1:300 STATE HIGHWAY 1947
Practice Address - Street 2:
Practice Address - City:GRAYSON
Practice Address - State:KY
Practice Address - Zip Code:41143
Practice Address - Country:US
Practice Address - Phone:606-474-2200
Practice Address - Fax:606-474-2205
Is Sole Proprietor?:No
Enumeration Date:2006-08-25
Last Update Date:2012-09-07
Deactivation Date:2007-03-21
Deactivation Code:
Reactivation Date:2007-07-19
Provider Licenses
StateLicense IDTaxonomies
KY32686207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2016446Medicaid
KY64326861Medicaid
0652202Medicare PIN
OH2016446Medicaid