Provider Demographics
NPI:1669115788
Name:GUPTA, SHRUTI
Entity type:Individual
Prefix:
First Name:SHRUTI
Middle Name:
Last Name:GUPTA
Suffix:
Gender:F
Credentials:
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 840026
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75284-0026
Mailing Address - Country:US
Mailing Address - Phone:806-212-5079
Mailing Address - Fax:
Practice Address - Street 1:1600 WALLACE BLVD
Practice Address - Street 2:
Practice Address - City:AMARILLO
Practice Address - State:TX
Practice Address - Zip Code:79106-1789
Practice Address - Country:US
Practice Address - Phone:806-212-2129
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-04-16
Last Update Date:2025-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXV9614207R00000X
TXBP10081434390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine