Provider Demographics
NPI:1871604629
Name:GUPTA, MANU ALEXANDER (MD)
Entity type:Individual
Prefix:
First Name:MANU
Middle Name:ALEXANDER
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 18139
Mailing Address - Street 2:
Mailing Address - City:RALEIGH
Mailing Address - State:NC
Mailing Address - Zip Code:27619-8139
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4420 LAKE BOONE TRL
Practice Address - Street 2:
Practice Address - City:RALEIGH
Practice Address - State:NC
Practice Address - Zip Code:27607-7505
Practice Address - Country:US
Practice Address - Phone:919-784-3034
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-31
Last Update Date:2007-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC9800259207L00000X, 208VP0014X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
No208VP0014XAllopathic & Osteopathic PhysiciansPain MedicineInterventional Pain Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC35263OtherPARTNERS
NC89132EPMedicaid
NC132EPOtherBCBS NC
NC89469OtherMEDCOST
NC5705985OtherCIGNA
NC89469OtherMEDCOST
NCG68083Medicare UPIN