Provider Demographics
NPI:1043298870
Name:GUPTA, SANJAY K (MD)
Entity type:Individual
Prefix:DR
First Name:SANJAY
Middle Name:K
Last Name:GUPTA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6500 29TH ST
Mailing Address - Street 2:SUITE 106
Mailing Address - City:GREELEY
Mailing Address - State:CO
Mailing Address - Zip Code:80634-8386
Mailing Address - Country:US
Mailing Address - Phone:970-330-5555
Mailing Address - Fax:970-584-1055
Practice Address - Street 1:6500 29TH STREET
Practice Address - Street 2:SUITE 106
Practice Address - City:GREELEY
Practice Address - State:CO
Practice Address - Zip Code:80634-8386
Practice Address - Country:US
Practice Address - Phone:970-330-5555
Practice Address - Fax:970-584-1055
Is Sole Proprietor?:No
Enumeration Date:2006-01-03
Last Update Date:2011-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO41311207Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO80585019Medicaid
CO494138Medicare ID - Type Unspecified
COC494138Medicare PIN
CO80585019Medicaid